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Organization Active NPI

Heritage Manor Bloomington, LLC

Doing business as Heritage Health - Bloomington

  • Skilled Nursing Facility
  • Bloomington, IL
National Provider Identifier
1457343170
Registry record updated May 27, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
48157 Issued in IL
Legal business name
HERITAGE MANOR BLOOMINGTON, LLC
Doing business as
Heritage Health - Bloomington
Practice address
700 E Walnut St
Bloomington, IL 61701-3244
Phone
(309) 827-8004
Fax
(309) 827-0256
NPI assigned
Aug 18, 2005
Last updated
May 27, 2014By the provider in NPPES
Organization subpart
Yes
Parent organization
HERITAGE ENTERPRISES, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 27, 2014

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

Authorized official

Name
David M Underwood
Title
Sr. VP & Cfo
Phone
(309) 828-4361

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Occupational Therapy Assistant 224Z00000X IL
Geriatric Physical Therapist 2251G0304X IL
Physical Therapy Assistant 225200000X IL
Speech-Language Pathologist 235Z00000X IL
Skilled Nursing Facility 314000000X 48157 IL Primary
Oxygen Equipment & Supplies (DME) 332BX2000X 48157 IL
Physical Rehabilitation Occupational Therapist 225XP0019X IL

Addresses

Primary practice location

700 E Walnut St
Bloomington, IL 61701-3244

Mailing address

115 W Jefferson St
Suite 401
Bloomington, IL 61701-3946
Phone (309) 828-4361

Other names 1

  • Heritage Health - Bloomington Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Heritage Enterprises Inc13 organizations share this tax ID, including this one
Part of
Heritage Enterprises Inc

Other organizations with this tax ID 12

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

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

{
    "created_epoch": "1124323200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1401148800000",
    "number": "1457343170",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "115 W JEFFERSON ST",
            "address_2": "SUITE 401",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617013946",
            "telephone_number": "309-828-4361",
            "fax_number": "309-829-5477"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 E WALNUT ST",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617013244",
            "telephone_number": "309-827-8004",
            "fax_number": "309-827-0256"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HERITAGE MANOR BLOOMINGTON, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "HERITAGE ENTERPRISES, INC",
        "enumeration_date": "2005-08-18",
        "last_updated": "2014-05-27",
        "status": "A",
        "authorized_official_last_name": "UNDERWOOD",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "SR. VP & CFO",
        "authorized_official_telephone_number": "309-828-4361"
    },
    "taxonomies": [
        {
            "code": "224Z00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapy Assistant",
            "state": "IL",
            "license": null,
            "primary": false
        },
        {
            "code": "2251G0304X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Geriatrics",
            "state": "IL",
            "license": null,
            "primary": false
        },
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "IL",
            "license": null,
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "IL",
            "license": null,
            "primary": false
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "48157",
            "primary": true
        },
        {
            "code": "332BX2000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Oxygen Equipment & Supplies",
            "state": "IL",
            "license": "48157",
            "primary": false
        },
        {
            "code": "225XP0019X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist, Physical Rehabilitation",
            "state": "IL",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Heritage Health - Bloomington",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bloomington, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 27, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.