Provider Demographics
NPI:1962896431
Name:PRESENCE HERITAGE DAY BREAK
Entity type:Organization
Organization Name:PRESENCE HERITAGE DAY BREAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-478-7911
Mailing Address - Street 1:1025 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2059
Mailing Address - Country:US
Mailing Address - Phone:815-937-2447
Mailing Address - Fax:708-478-5387
Practice Address - Street 1:1025 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2059
Practice Address - Country:US
Practice Address - Phone:815-937-2447
Practice Address - Fax:708-478-5387
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESENCE LIFE CONNECTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILADS1002010OtherILLINOIS DEPARTMENT OF AGING