Provider Demographics
NPI:1710156609
Name:HERITAGE ENTERPRISES, INC.
Entity Type:Organization
Organization Name:HERITAGE ENTERPRISES, INC.
Other - Org Name:EVERGREEN PLACE SUPPORTIVE LIVING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR V. P. OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:115 W JEFFERSON ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3946
Mailing Address - Country:US
Mailing Address - Phone:309-823-7155
Mailing Address - Fax:309-829-9512
Practice Address - Street 1:8570 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-9200
Practice Address - Country:US
Practice Address - Phone:217-323-4055
Practice Address - Fax:217-323-9454
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE MANOR - BEARDSTOWN SOUTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1825445310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========028Medicaid