Active NPI
Monroe County
Doing business as Magnolia Terrace
- Assisted Living Facility
- Waterloo, IL
National Provider Identifier
1457500621
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Assisted Living Facility
- Legal business name
- MONROE COUNTY
- Doing business as
- Magnolia Terrace
- Practice address
- 623 Hamacher Street
Waterloo, IL 62298-1598 - Phone
- (618) 939-0500
- Fax
- (618) 939-4906
- NPI assigned
- Sep 12, 2008
- Last updated
- Jun 25, 2015
- Organization subpart
- Yes
- Parent organization
- MONROE COUNTY
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mrs. Kim Lee Keckritz
- Title
- Administrator
- Phone
- (618) 939-3488
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Assisted Living Facility | 310400000X | IL | Primary |
Addresses
Primary practice location
623 Hamacher Street
Waterloo, IL 62298-1598
Mailing address
623 Hamacher Street
Waterloo, IL 62298-1598
Phone (618) 939-0500
Other names 1
- Magnolia Terrace
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 14D2221330 | Magnolia Terrace | Certificate of waiver | Apr 19, 2027 |
National Provider Directory
National Provider Directory- Tax ID family
- Monroe County
- Part of
- Monroe County
Other organizations with this tax ID 2
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": "1221177600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1435190400000",
"number": "1457500621",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "623 HAMACHER STREET",
"city": "WATERLOO",
"state": "IL",
"postal_code": "622981598",
"telephone_number": "618-939-0500",
"fax_number": "618-939-4906"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "623 HAMACHER STREET",
"city": "WATERLOO",
"state": "IL",
"postal_code": "622981598",
"telephone_number": "618-939-0500",
"fax_number": "618-939-4906"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "MONROE COUNTY",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "MONROE COUNTY",
"enumeration_date": "2008-09-12",
"last_updated": "2015-06-25",
"status": "A",
"authorized_official_last_name": "KECKRITZ",
"authorized_official_first_name": "KIM",
"authorized_official_middle_name": "LEE",
"authorized_official_title_or_position": "ADMINISTRATOR",
"authorized_official_telephone_number": "618-939-3488",
"authorized_official_name_prefix": "Mrs."
},
"taxonomies": [
{
"code": "310400000X",
"taxonomy_group": "",
"desc": "Assisted Living Facility",
"state": "IL",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "Magnolia Terrace",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Waterloo, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- 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.