Provider Demographics
NPI:1457623753
Name:MATTOON MANOR, LLC
Entity type:Organization
Organization Name:MATTOON MANOR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATOR, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:TUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-444-0900
Mailing Address - Street 1:2121 SOUTH 9TH
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-6113
Mailing Address - Country:US
Mailing Address - Phone:217-235-7138
Mailing Address - Fax:217-235-7140
Practice Address - Street 1:2121 SOUTH 9TH
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-6113
Practice Address - Country:US
Practice Address - Phone:217-235-7138
Practice Address - Fax:217-235-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145480Medicare Oscar/Certification