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General NPI Number Information
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NPI Number | 1053715995
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Entity Type | Organization
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Legal Business Name | THE ESTATES OF SPANISH LAKE, LLC
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Dates
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Enumeration Date | 10/21/2014
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Last Update Date | 03/09/2016
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Provider Practice Location Address
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Address Line | 610 PRIGGE RD
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City | SAINT LOUIS
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State | MO
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Zip | 63138-3543
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Country | US
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Telephone | 610-828-8700
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Fax |
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Provider Business Mailing Address
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Address Line | 5940 W TOUHY AVE STE 350
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City | NILES
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State | IL
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Zip | 60714-4638
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | TUVIYAH SPECTOR
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Credential |
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Telephone | 773-322-0387
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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