MEDICARE: WATERVIEW WOODS ASSISTED LIVING 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	:	1548826456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERVIEW WOODS ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	8833 GROSS POINT RD STE 208
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-1859
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 GRANT AVE
Second Line	:
City	:	EVELETH
State	:	MN
Zip	:	55734-1314
Country	:	US
Telephone Number	:	218-744-9800
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOSH LEGUM
Credential	:
Telephone Number	:	507-203-1001

Provider Enumeration Date	:	05/15/2019
Last Update Date	:	05/15/2019

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