Provider Demographics
NPI:1972946382
Name:FOX MEADOWS SLF LP
Entity Type:Organization
Organization Name:FOX MEADOWS SLF LP
Other - Org Name:HERITAGE WOODS OF MCLEANSBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:MILLENBINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-643-2908
Mailing Address - Street 1:605 S MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-1267
Mailing Address - Country:US
Mailing Address - Phone:618-643-2908
Mailing Address - Fax:
Practice Address - Street 1:605 S MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1267
Practice Address - Country:US
Practice Address - Phone:618-643-2908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE WOODS OF MCLEANSBORO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid