Healthcare Provider Details

I. General information

NPI: 1912916966
Provider Name (Legal Business Name): LONG GROVE MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 CHECKER RD
LONG GROVE IL
60047-5289
US

IV. Provider business mailing address

1666 CHECKER RD
LONG GROVE IL
60047-5289
US

V. Phone/Fax

Practice location:
  • Phone: 847-419-1111
  • Fax: 847-419-1119
Mailing address:
  • Phone: 847-419-1111
  • Fax: 847-419-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0040899
License Number StateIL

VIII. Authorized Official

Name: GLENN LEFKOVITZ
Title or Position: MANAGER
Credential:
Phone: 224-377-2400