Provider Demographics
NPI:1285885509
Name:HERITAGE WOODS OF CENTRALIA, LLC
Entity type:Organization
Organization Name:HERITAGE WOODS OF CENTRALIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:IOERGER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:618-532-4590
Mailing Address - Street 1:2049 E MCCORD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-6784
Mailing Address - Country:US
Mailing Address - Phone:618-532-4590
Mailing Address - Fax:
Practice Address - Street 1:2049 E MCCORD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-6784
Practice Address - Country:US
Practice Address - Phone:618-532-4590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6280101Medicaid