Provider Demographics
NPI:1699949834
Name:MEADOWS MENNONITE RETIREMENT COMMUNITY
Entity type:Organization
Organization Name:MEADOWS MENNONITE RETIREMENT COMMUNITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, SHOW BUS
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ROBERTS
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-747-2454
Mailing Address - Street 1:24588 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHENOA
Mailing Address - State:IL
Mailing Address - Zip Code:61726-9395
Mailing Address - Country:US
Mailing Address - Phone:309-747-2454
Mailing Address - Fax:
Practice Address - Street 1:24588 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHENOA
Practice Address - State:IL
Practice Address - Zip Code:61726-9395
Practice Address - Country:US
Practice Address - Phone:309-747-2454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEADOWS MENNONITE RETIREMENT COMMUNITY ASSOCIATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-18
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL61726-03347B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347B00000XTransportation ServicesBus
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-61726-03Medicaid