MEDICARE: A GREAT PLACE TO STAY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1053949404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A GREAT PLACE TO STAY LLC

Provider Business Mailing Address
First Line	:	716 PARK AVE
Second Line	:
City	:	BEAVER DAM
State	:	WI
Zip	:	53916-2204
Country	:	US
Telephone Number	:	920-204-2722
Fax Number	:

Provider Business Practice Location Address
First Line	:	35580 N KNOWLES RD
Second Line	:
City	:	LAKE VILLA
State	:	IL
Zip	:	60046-9026
Country	:	US
Telephone Number	:	920-204-2722
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VERONICA CLARK
Credential	:
Telephone Number	:	920-204-2722

Provider Enumeration Date	:	03/31/2020
Last Update Date	:	03/31/2020

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Directions to “A GREAT PLACE TO STAY LLC ” Practice Location

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