Provider Demographics
NPI:1700877545
Name:INDEPENDENT ORDER OF ODD FELLOWS
Entity Type:Organization
Organization Name:INDEPENDENT ORDER OF ODD FELLOWS
Other - Org Name:ODD FELLOW REBEKAH HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:201 LAFAYETTE AVE E
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4641
Mailing Address - Country:US
Mailing Address - Phone:217-235-5449
Mailing Address - Fax:217-235-0611
Practice Address - Street 1:201 LAFAYETTE AVE E
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4641
Practice Address - Country:US
Practice Address - Phone:217-235-5449
Practice Address - Fax:217-235-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0010223314000000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========801OtherMEDICAID OXYGEN PROVIDER NUMBER
IL=========001Medicaid
IL145772Medicare Oscar/Certification