Provider Demographics
NPI:1891024691
Name:NORTHEASTERN NURSING & REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:NORTHEASTERN NURSING & REHABILITATION CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER OF LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:HEDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-528-2244
Mailing Address - Street 1:1625 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2828
Mailing Address - Country:US
Mailing Address - Phone:217-528-2244
Mailing Address - Fax:217-528-3412
Practice Address - Street 1:2600 REDMAN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-5863
Practice Address - Country:US
Practice Address - Phone:314-355-8585
Practice Address - Fax:314-355-4645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265586Medicare Oscar/Certification