Provider Demographics
NPI:1013182807
Name:HICKORY ESTATES
Entity Type:Organization
Organization Name:HICKORY ESTATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PETER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:NARISH
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:618-936-2004
Mailing Address - Street 1:310 OTHA STREET
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:IL
Mailing Address - Zip Code:62466
Mailing Address - Country:US
Mailing Address - Phone:618-936-2004
Mailing Address - Fax:618-936-2556
Practice Address - Street 1:310 OTHA STREET
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:IL
Practice Address - Zip Code:62466-0164
Practice Address - Country:US
Practice Address - Phone:618-936-2004
Practice Address - Fax:618-936-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0030510315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14G105Medicaid