Heritage Manor - Mendota, LLC

Primary specialty

Oxygen Equipment & Supplies (DME)Taxonomy code 332BX2000X

Legal business name

HERITAGE MANOR - MENDOTA, LLC

Practice address

1201 1St Ave
Mendota, IL 61342-1815

Phone

(815) 539-6745

Fax

(815) 538-2017

NPI assigned

Nov 19, 2012

Organization subpart

Yes

Parent organization

HERITAGE ENTERPRISES, INCAs reported in NPPES

Name

David M Underwood, CPA

Title

Sr. VP, Cfo

Phone

(309) 823-7135

Part of

Heritage Enterprises Inc

• Heritage Health - Mendota Doing business as

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Apr 24, 2014.

{
    "created_epoch": "1353283200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1398297600000",
    "number": "1982948683",
    "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": "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": "2012-11-19",
        "last_updated": "2014-04-24",
        "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": "309-823-7135",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "332BX2000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Oxygen Equipment & Supplies",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Heritage Health - Mendota",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Alicia Foster
• Marissa Gatza, C.O.T.A.
• Kristi Gonzales, PA-C
• Goslin Drug Store Inc
• Pamela A Hansen, PA-C
• Heritage Manor Mendota, LLC
• Highland Park CVS, L.L.C.
• Ashlee Hoff, OTR
• Joshua Chase Humphrey, O.T.R.
• Sharon Jones Burtlow, FNP-BC

• All providers in Mendota, IL
• Oxygen Equipment & Supplies (DME) in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 24, 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.