Provider Demographics
NPI:1831248228
Name:ILLINOIS VETERANS HOME AT MANTENO
Entity type:Organization
Organization Name:ILLINOIS VETERANS HOME AT MANTENO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:815-468-6581
Mailing Address - Street 1:1 VETERANS DR
Mailing Address - Street 2:BLDG A-2M
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-9466
Mailing Address - Country:US
Mailing Address - Phone:217-222-9487
Mailing Address - Fax:217-222-8578
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-9466
Practice Address - Country:US
Practice Address - Phone:815-468-6581
Practice Address - Fax:815-468-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0042218311ZA0620X, 320700000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
04621430OtherBCBS
CI2630Medicare PIN
0650890001Medicare NSC
226040Medicare PIN