MEDICARE: THE WATERS OF FORT WAYNE SKILLED NURSING FACILITY 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1194433946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WATERS OF FORT WAYNE SKILLED NURSING FACILITY LLC

Provider Business Mailing Address
First Line	:	240 FENCL LN
Second Line	:
City	:	HILLSIDE
State	:	IL
Zip	:	60162-2067
Country	:	US
Telephone Number	:	708-449-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	5544 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7475
Country	:	US
Telephone Number	:	260-749-9506
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JEFFREY SAX
Credential	:
Telephone Number	:	219-898-5705

Provider Enumeration Date	:	11/10/2022
Last Update Date	:	11/10/2022

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