Provider Demographics
NPI:1245437797
Name:HICKORY ESTATES OF PANA LLC
Entity type:Organization
Organization Name:HICKORY ESTATES OF PANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-562-2022
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-0086
Mailing Address - Country:US
Mailing Address - Phone:217-562-2022
Mailing Address - Fax:217-562-2027
Practice Address - Street 1:101 N HICKORY ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1040
Practice Address - Country:US
Practice Address - Phone:217-562-2022
Practice Address - Fax:217-562-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid