Healthcare Provider Details

I. General information

NPI: 1043928807
Provider Name (Legal Business Name): THE WATERS OF LAGRANGE SKILLED NURSING FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 N DETROIT ST
LAGRANGE IN
46761-1111
US

IV. Provider business mailing address

240 FENCL LN
HILLSIDE IL
60162-2067
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-2172
  • Fax:
Mailing address:
  • Phone: 708-449-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY SAX
Title or Position: MANAGER
Credential:
Phone: 219-898-5705