Provider Demographics
NPI:1164766861
Name:HERITAGE MANOR - PERU, LLC
Entity type:Organization
Organization Name:HERITAGE MANOR - PERU, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
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 1:1301 21ST ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1359
Practice Address - Country:US
Practice Address - Phone:815-223-4901
Practice Address - Fax:815-224-2497
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-19
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies