Provider Demographics
NPI:1013986439
Name:NEW ATHENS HOME FOR THE AGED INC
Entity Type:Organization
Organization Name:NEW ATHENS HOME FOR THE AGED INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:WYNN
Authorized Official - Last Name:HOLTGREWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-475-2550
Mailing Address - Street 1:203 S JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:NEW ATHENS
Mailing Address - State:IL
Mailing Address - Zip Code:62264-1319
Mailing Address - Country:US
Mailing Address - Phone:618-475-2550
Mailing Address - Fax:618-475-2567
Practice Address - Street 1:203 S JOHNSON ST
Practice Address - Street 2:
Practice Address - City:NEW ATHENS
Practice Address - State:IL
Practice Address - Zip Code:62264-1319
Practice Address - Country:US
Practice Address - Phone:618-475-2550
Practice Address - Fax:618-475-2567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0033043313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14E299OtherPUBLIC HEALTH ID #
IL14-0061Medicaid
IL972110Medicare ID - Type UnspecifiedPART B PROVIDER #