Provider Demographics
NPI:1942367453
Name:ILLINOIS VETERANS HOME AT LASALLE
Entity Type:Organization
Organization Name:ILLINOIS VETERANS HOME AT LASALLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:815-223-0303
Mailing Address - Street 1:1015 OCONOR AVE
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-1216
Mailing Address - Country:US
Mailing Address - Phone:217-222-9487
Mailing Address - Fax:217-222-8578
Practice Address - Street 1:1015 OCONOR AVE
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-1216
Practice Address - Country:US
Practice Address - Phone:815-223-0303
Practice Address - Fax:815-223-5815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL44115311ZA0620X, 320700000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
05032039OtherBCBS
DC8121Medicare PIN
0636590001Medicare NSC
05032039OtherBCBS