Mulberry Manor, Inc.

Primary specialty

Intellectual and/or Developmental Disabilities Residential Treatment FacilityTaxonomy code 320600000X

Legal business name

MULBERRY MANOR, INC.

Practice address

612 E Davie
Anna, IL 62906-0088

Phone

(618) 833-6012

NPI assigned

Apr 13, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Joann Keller

Title

Administrator

Phone

(618) 833-6012

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Intermediate care facility for individuals with intellectual disabilities certification: CCN 14G001

Legal name

MULBERRY MANOR

Certification status

Active

Provider type (POS)

Intermediate care facility for individuals with intellectual disabilities

Participating since

May 20, 1988

Last certification

Aug 16, 2024

Beds

64 (51 certified)

Ownership / control type

Private (non-profit)

Facility address

612 East Davie Street, Box 88
Anna, IL 62906

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1164646550",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 88",
            "city": "ANNA",
            "state": "IL",
            "postal_code": "629060088",
            "telephone_number": "618-833-6012"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "612 E DAVIE",
            "city": "ANNA",
            "state": "IL",
            "postal_code": "629060088",
            "telephone_number": "618-833-6012"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MULBERRY MANOR, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-13",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "KELLER",
        "authorized_official_first_name": "JOANN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "618-833-6012"
    },
    "taxonomies": [
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Intellectual and/or Developmental Disabilities Residential Treatment Facility in Anna, IL
• Providers in Anna, IL by specialty
• Intellectual and/or Developmental Disabilities Residential Treatment Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.