MEDICARE: HALLOWSTONE IGH OPERATING 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1457221905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HALLOWSTONE IGH OPERATING LLC

Provider Business Mailing Address
First Line	:	12811 KENWOOD LN STE 218
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-5645
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5891 CARMEN AVE
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-4414
Country	:	US
Telephone Number	:	239-292-1513
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	AYLA HARWOOD
Credential	:
Telephone Number	:	239-292-1513

Provider Enumeration Date	:	11/10/2025
Last Update Date	:	12/11/2025

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