MEDICARE: VILLA AT ST LOUIS PARK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1588008676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLA AT ST LOUIS PARK LLC

Provider Business Mailing Address
First Line	:	3701 W LUNT AVE
Second Line	:
City	:	LINCOLNWOOD
State	:	IL
Zip	:	60712-2615
Country	:	US
Telephone Number	:	847-440-2660
Fax Number	:

Provider Business Practice Location Address
First Line	:	7500 W 22ND ST
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-2602
Country	:	US
Telephone Number	:	952-546-4261
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	BENJAMIN ISRAEL
Credential	:
Telephone Number	:	847-440-2665

Provider Enumeration Date	:	04/19/2013
Last Update Date	:	03/18/2021

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