Provider Demographics
NPI:1821317041
Name:CASTLE MANOR
Entity Type:Organization
Organization Name:CASTLE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC VP & CFO
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 STE 401
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3967
Mailing Address - Country:US
Mailing Address - Phone:309-823-7155
Mailing Address - Fax:309-829-9512
Practice Address - Street 1:1550 CASTLE MANOR DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-6000
Practice Address - Country:US
Practice Address - Phone:217-732-2310
Practice Address - Fax:217-732-2359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2010-09-13
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