Heritage Manor Mendota, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

48108 Issued in IL

Legal business name

HERITAGE MANOR MENDOTA, LLC

Doing business as

Heritage Health - Mendota

Practice address

1201 1St Ave
Mendota, IL 61342-1815

Phone

(815) 539-6745

Fax

(815) 538-2017

NPI assigned

Oct 28, 2005

Last updated

May 27, 2014By the provider in NPPES

Organization subpart

Yes

Parent organization

HERITAGE ENTERPRISES, INCAs reported in NPPES

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

Authorized official

Name

Mr. David M Underwood

Title

Sr. VP & Cfo

Phone

(309) 828-4361

Specialties & licenses 2

Addresses

Other names 1

• Heritage Health - Mendota Doing business as

Part of

Heritage Enterprises Inc

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

{
    "created_epoch": "1130457600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1401148800000",
    "number": "1871583906",
    "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": "309-829-9512"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1201 1ST AVE",
            "city": "MENDOTA",
            "state": "IL",
            "postal_code": "613421815",
            "telephone_number": "815-539-6745",
            "fax_number": "815-538-2017"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HERITAGE MANOR MENDOTA, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "HERITAGE ENTERPRISES, INC",
        "enumeration_date": "2005-10-28",
        "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",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "48108",
            "primary": true
        },
        {
            "code": "332BX2000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Oxygen Equipment & Supplies",
            "state": "IL",
            "license": "0048108",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Heritage Health - Mendota",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Marissa Gatza, C.O.T.A.
• Kristi Gonzales, PA-C
• Goslin Drug Store Inc
• Pamela A Hansen, PA-C
• Heritage Manor - Mendota, LLC (Heritage Health - Mendota)
• Highland Park CVS, L.L.C. (CVS Pharmacy # 06897)
• Ashlee Hoff, OTR
• Joshua Chase Humphrey, O.T.R.
• Sharon Jones Burtlow, FNP-BC
• Tracie R Kelly, APRN

• Skilled Nursing Facility in Mendota, IL
• Providers in Mendota, IL by specialty
• Skilled Nursing Facility in Illinois

• 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.