Provider Demographics
NPI:1588008676
Name:VILLA AT ST LOUIS PARK LLC
Entity Type:Organization
Organization Name:VILLA AT ST LOUIS PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISRAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-440-2665
Mailing Address - Street 1:3701 W LUNT AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2615
Mailing Address - Country:US
Mailing Address - Phone:847-440-2660
Mailing Address - Fax:
Practice Address - Street 1:7500 W 22ND ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-2602
Practice Address - Country:US
Practice Address - Phone:952-546-4261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
245182Medicare Oscar/Certification