Provider Demographics
NPI:1700819778
Name:LTC OF ILLINOIS - FIRESIDE, INC.
Entity type:Organization
Organization Name:LTC OF ILLINOIS - FIRESIDE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:MITTLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-619-0866
Mailing Address - Street 1:1030 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3002
Mailing Address - Country:US
Mailing Address - Phone:618-532-1833
Mailing Address - Fax:618-532-1308
Practice Address - Street 1:1030 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3002
Practice Address - Country:US
Practice Address - Phone:618-532-1833
Practice Address - Fax:618-532-1308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0045690314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========01Medicaid
14-5791Medicare ID - Type Unspecified