MEDICARE: GLEN SAINT ANDREW LIVING COMMUNITY, 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	0053348	IL

General Provider Information

NPI Number	:	1639577851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLEN SAINT ANDREW LIVING COMMUNITY, LLC

Provider Business Mailing Address
First Line	:	7000 N NEWARK AVE
Second Line	:
City	:	NILES
State	:	IL
Zip	:	60714-4577
Country	:	US
Telephone Number	:	847-647-8332
Fax Number	:	847-647-7073

Provider Business Practice Location Address
First Line	:	5454 FARGO AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-3210
Country	:	US
Telephone Number	:	847-674-7370
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OF OPERATIONS
Name	:	JOSHUA D RAY
Credential	:
Telephone Number	:	847-421-3851

Provider Enumeration Date	:	12/22/2014
Last Update Date	:	12/22/2014

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