Organization
HERITAGE MANOR - EL PASO, LLC
Active
Parent organization
HERITAGE ENTERPRISES, INC
Other names
Heritage Health - El Paso
Organization subpart
Yes
Provider details
NPI number
Legal business name
HERITAGE ENTERPRISES, INC
Authorized official
MR. DAVID M UNDERWOOD (SR. VP & CFO)
(309) 828-4361
Entity
Organization
Contact information
Practice address
555 E CLAY ST, EL PASO, IL 61738-1508
(309) 527-6240
(309) 527-6243
Mailing address
115 W JEFFERSON ST, SUITE 401, BLOOMINGTON, IL 61701-3946
(309) 828-4361
(309) 829-9512
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
48124
IL
332BX2000X
Oxygen Equipment & Supplies (DME)
0048124
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2039003447-801
MEDICAID OXYGEN PROVIDER
IL
Enumeration date
10/28/2005
Last updated
04/06/2022
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