Provider Demographics
NPI:1801850177
Name:AMERICAN LUTHERAN CHURCH MENDOTA
Entity Type:Organization
Organization Name:AMERICAN LUTHERAN CHURCH MENDOTA
Other - Org Name:MENDOTA LUTHERAN HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FALK
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, LNHA
Authorized Official - Phone:815-539-7439
Mailing Address - Street 1:500 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-1728
Mailing Address - Country:US
Mailing Address - Phone:815-539-7439
Mailing Address - Fax:815-538-3400
Practice Address - Street 1:500 6TH ST
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1728
Practice Address - Country:US
Practice Address - Phone:815-539-7439
Practice Address - Fax:815-538-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0011593313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL146072Medicare ID - Type Unspecified