Provider Demographics
NPI:1235688003
Name:HICKORY ESTATES OF TAYLORVILLE, LLC
Entity type:Organization
Organization Name:HICKORY ESTATES OF TAYLORVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-824-3355
Mailing Address - Street 1:1091 E 1500 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-9500
Mailing Address - Country:US
Mailing Address - Phone:217-824-3355
Mailing Address - Fax:217-824-3375
Practice Address - Street 1:1091 E 1500 NORTH RD
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-9500
Practice Address - Country:US
Practice Address - Phone:217-824-3355
Practice Address - Fax:217-824-3375
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHRISTIAN COUNTY INTEGRATED COMMUNITY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility