Organization
HICKORY ESTATES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. PETER MICHAEL NARISH ADMINISTRATOR (ADMINISTRATOR)
(618) 936-2004
Entity
Organization
Contact information
Practice address
310 OTHA STREET, SUMNER, IL 62466-0164
(618) 936-2004
(618) 936-2556
Mailing address
310 OTHA STREET, SUMNER, IL 62466
(618) 936-2004
(618) 936-2556
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
0030510
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
14G105
—
IL
Enumeration date
04/23/2008
Last updated
04/23/2008
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