Provider Demographics
NPI:1881636603
Name:HOOPESTON RETIREMENT VILLAGE FOUNDATION
Entity Type:Organization
Organization Name:HOOPESTON RETIREMENT VILLAGE FOUNDATION
Other - Org Name:HERITAGE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP OF FINANCE, 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 1:115 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:309-828-4361
Mailing Address - Fax:309-829-5477
Practice Address - Street 1:423 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1021
Practice Address - Country:US
Practice Address - Phone:217-283-8247
Practice Address - Fax:217-283-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0035022314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363637465001Medicaid
IL732OtherBCBS NURSING HOME
IL145470Medicare Oscar/Certification