Provider Demographics
NPI:1689819955
Name:HERITAGE WOODS OF MOLINE SUPPORTIVE LIVING FACILITY, LP
Entity Type:Organization
Organization Name:HERITAGE WOODS OF MOLINE SUPPORTIVE LIVING FACILITY, LP
Other - Org Name:HERITAGE WOODS OF MOLINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:D.
Authorized Official - Middle Name:EILEEN
Authorized Official - Last Name:MOSELEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PN, LNHA
Authorized Official - Phone:309-736-5655
Mailing Address - Street 1:5500 46TH AVENUE DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-9760
Mailing Address - Country:US
Mailing Address - Phone:309-736-5655
Mailing Address - Fax:309-736-5651
Practice Address - Street 1:5500 46TH AVENUE DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-9760
Practice Address - Country:US
Practice Address - Phone:309-736-5655
Practice Address - Fax:309-736-5651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid