MEDICARE: GRAND VICTORIAN OF STERLING MASTER LESSEE, 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	305S00000X	Point of Service

General Provider Information

NPI Number	:	1558512723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND VICTORIAN OF STERLING MASTER LESSEE, LLC

Provider Business Mailing Address
First Line	:	78 CENTENNIAL LOOP
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-7900
Country	:	US
Telephone Number	:	541-747-3373
Fax Number	:	541-868-8447

Provider Business Practice Location Address
First Line	:	2705 AVENUE E
Second Line	:
City	:	STERLING
State	:	IL
Zip	:	61081-9016
Country	:	US
Telephone Number	:	815-622-2800
Fax Number	:	815-622-2801

Authorized Official
Title or Position	:	CONTROLLER
Name	:	JOHN HOLTZ
Credential	:
Telephone Number	:	541-747-3373

Provider Enumeration Date	:	10/07/2008
Last Update Date	:	10/07/2008

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