Provider Demographics
NPI:1366786444
Name:HERITAGE MANOR - LASALLE, LLC
Entity type:Organization
Organization Name:HERITAGE MANOR - LASALLE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC VP
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:1445 CHARTRES ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-1508
Mailing Address - Country:US
Mailing Address - Phone:815-223-4700
Mailing Address - Fax:815-223-4708
Practice Address - Street 1:115 W JEFFERSON ST
Practice Address - Street 2:SUITE 401
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3946
Practice Address - Country:US
Practice Address - Phone:309-828-4361
Practice Address - Fax:309-829-5477
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies