Provider Demographics
NPI:1932205713
Name:HERRIN REHABILITATION AND NURSING CENTER, LLC
Entity Type:Organization
Organization Name:HERRIN REHABILITATION AND NURSING CENTER, LLC
Other - Org Name:WILLOW OF HERRIN, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:C.F.O
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLISKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-426-2315
Mailing Address - Street 1:4213 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2046
Mailing Address - Country:US
Mailing Address - Phone:708-426-2315
Mailing Address - Fax:708-236-0001
Practice Address - Street 1:1900 N PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-2742
Practice Address - Country:US
Practice Address - Phone:618-942-2525
Practice Address - Fax:618-988-1683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040717314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid