Provider Demographics
NPI:1720055809
Name:MEDINA NURSING CENTER, INC
Entity Type:Organization
Organization Name:MEDINA NURSING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HOLGEIR
Authorized Official - Middle Name:J
Authorized Official - Last Name:OKSNEVAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-248-2151
Mailing Address - Street 1:402 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:IL
Mailing Address - Zip Code:61024-9590
Mailing Address - Country:US
Mailing Address - Phone:815-248-2151
Mailing Address - Fax:815-248-2771
Practice Address - Street 1:402 CENTER ST
Practice Address - Street 2:
Practice Address - City:DURAND
Practice Address - State:IL
Practice Address - Zip Code:61024-9590
Practice Address - Country:US
Practice Address - Phone:815-248-2151
Practice Address - Fax:815-248-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0011551314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
IL=========Medicaid