MEDICARE: VILLAS AT THE PARK 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	:	1669182135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAS AT THE PARK LLC

Provider Business Mailing Address
First Line	:	2361 NOSTRAND AVE STE 903
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3953
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4415 W 36 1/2 ST
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4854
Country	:	US
Telephone Number	:	952-927-9717
Fax Number	:

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

Provider Enumeration Date	:	11/25/2022
Last Update Date	:	11/25/2022

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Directions to “VILLAS AT THE PARK LLC ” Practice Location

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