1043928807 NPI number — THE WATERS OF LAGRANGE SKILLED NURSING FACILITY LLC

Table of content: (NPI 1043928807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043928807 NPI number — THE WATERS OF LAGRANGE SKILLED NURSING FACILITY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WATERS OF LAGRANGE SKILLED NURSING FACILITY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1043928807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 FENCL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSIDE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60162-2067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-449-1900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
787 N DETROIT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46761-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-463-2172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SAX
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
219-898-5705

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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