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General NPI Number Information
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NPI Number | 1912916966
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Entity Type | Organization
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Legal Business Name | LONG GROVE MANOR INC
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Dates
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Enumeration Date | 08/07/2006
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Last Update Date | 02/09/2012
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Provider Practice Location Address
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Address Line | 1666 CHECKER RD
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City | LONG GROVE
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State | IL
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Zip | 60047-5289
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Country | US
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Telephone | 847-419-1111
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Fax | 847-419-1119
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Provider Business Mailing Address
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Address Line | 1666 CHECKER RD
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City | LONG GROVE
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State | IL
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Zip | 60047-5289
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Country | US
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Telephone | 847-419-1111
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Fax | 847-419-1119
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Authorized Official
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Title or Position | MANAGER
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Name | GLENN LEFKOVITZ
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Credential |
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Telephone | 224-377-2400
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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 | 0040899
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License Number State | IL
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