Provider Demographics
NPI:1952308744
Name:ILLINOIS KNIGHTS TEMPLAR HOME
Entity Type:Organization
Organization Name:ILLINOIS KNIGHTS TEMPLAR HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:450 E FULTON ST
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:IL
Mailing Address - Zip Code:60957-1716
Mailing Address - Country:US
Mailing Address - Phone:217-379-2116
Mailing Address - Fax:217-379-3000
Practice Address - Street 1:450 E FULTON ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1716
Practice Address - Country:US
Practice Address - Phone:217-379-2116
Practice Address - Fax:217-379-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0010058314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid