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General NPI Number Information
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NPI Number | 1639577851
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Entity Type | Organization
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Legal Business Name | GLEN SAINT ANDREW LIVING COMMUNITY, LLC
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Dates
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Enumeration Date | 12/22/2014
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Last Update Date | 12/22/2014
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Provider Practice Location Address
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Address Line | 5454 FARGO AVE
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City | SKOKIE
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State | IL
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Zip | 60077-3210
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Country | US
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Telephone | 847-674-7370
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Fax |
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Provider Business Mailing Address
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Address Line | 7000 N NEWARK AVE
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City | NILES
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State | IL
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Zip | 60714-4577
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Country | US
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Telephone | 847-647-8332
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Fax | 847-647-7073
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Authorized Official
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Title or Position | CHIEF OF OPERATIONS
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Name | JOSHUA D RAY
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Credential |
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Telephone | 847-421-3851
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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 | 0053348
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License Number State | IL
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