NPIMap

Organization Active NPI

Iroquois Memorial Hospital and Resident Home

  • Skilled Nursing Facility
  • Watseka, IL
National Provider Identifier
1992894802
Registry record updated Jan 31, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
0014464 Issued in IL
Legal business name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Practice address
200 E Fairman Avenue
Watseka, IL 60970-1644
Phone
(815) 432-5841
Fax
(815) 432-7821
NPI assigned
Oct 11, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 31, 2017

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

Authorized official

Name
Timothy L Smith
Title
Coo
Phone
(815) 432-7967

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 0014464 IL Primary

Addresses

Primary practice location

200 E Fairman Avenue
Watseka, IL 60970-1644

Mailing address

200 E Fairman Avenue
Watseka, IL 60970-1644
Phone (815) 432-5841

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20020903000000 IL Part A Provider - Skilled Nursing Facility 4385551258 Practice locations: Watseka, IL

Skilled nursing facility certification: CCN 146049

Legal name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Doing business as
IROQUOIS RESIDENT HOME
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Aug 18, 2003
Last certification
Jun 26, 2024
Beds
35
Ownership / control type
Nonprofit Corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 7, 1958 in IL
Enrollment address
200 E Fairman Ave
Watseka, IL 60970-1644
Nursing home name
IROQUOIS RESIDENT HOME, THE

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Nursing home

Medicare Care Compare
Listed as
Iroquois Resident Home, theCCN 146049
Overall star rating
4 of 5
Health inspections
4 of 5
Staffing
2 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
Non profit - Corporation
Certified
Aug 18, 2003
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
3533.4 residents per day on average

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory
Tax ID family
Iroquois Memorial Hospi15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

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

View all 14

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Michelle Fox Individual Operational/Managerial Control Sep 1, 2018
Adp of the SNF Sep 1, 2018
Crisanto M Reyes Individual Corporate Director Sep 1, 2018
Adp of the SNF Feb 12, 2025
Michael Tilstra Individual Corporate OfficerCeo Jan 17, 2022
Daniel Tincher Individual Corporate Director Jul 1, 2024
Denise Graves Individual Operational/Managerial Control Mar 27, 2025
Adp of the SNF Mar 27, 2025
Adam Knapp Individual Corporate Director Jan 1, 2025
Sara J Mikuta Individual Corporate Director Jul 1, 2024
Philip Zumwalt Individual Corporate Director Jul 26, 2022
Rhonda Pence Individual Corporate DirectorChairperson Feb 1, 2014
Roger Dittrich Individual Corporate Director Dec 21, 2024

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1160524800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1485820800000",
    "number": "1992894802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 E FAIRMAN AVENUE",
            "city": "WATSEKA",
            "state": "IL",
            "postal_code": "609701644",
            "telephone_number": "815-432-5841",
            "fax_number": "815-432-7821"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 E FAIRMAN AVENUE",
            "city": "WATSEKA",
            "state": "IL",
            "postal_code": "609701644",
            "telephone_number": "815-432-5841",
            "fax_number": "815-432-7821"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-11",
        "last_updated": "2017-01-31",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "815-432-7967"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "0014464",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Watseka, IL

Sources for this page

Verify at the official NPI Registry.