Provider Demographics
NPI:1679865455
Name:HERITAGE MANOR LASALLE, LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR LASALLE, LLC
Other - Org Name:HERITAGE HEALTH - LASALLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:1445 CHARTRES ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-1508
Mailing Address - Country:US
Mailing Address - Phone:815-223-4700
Mailing Address - Fax:815-223-4708
Practice Address - Street 1:1445 CHARTRES ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-1508
Practice Address - Country:US
Practice Address - Phone:815-223-4700
Practice Address - Fax:815-223-4708
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-11
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0051276314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-001Medicaid
IL145394Medicare Oscar/Certification