Provider Demographics
NPI:1629590310
Name:WATERS OF LEBANON LLC
Entity Type:Organization
Organization Name:WATERS OF LEBANON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOISHE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-449-1900
Mailing Address - Street 1:240 FENCL LN
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-2067
Mailing Address - Country:US
Mailing Address - Phone:708-449-1900
Mailing Address - Fax:
Practice Address - Street 1:1585 PERRY WORTH RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-9635
Practice Address - Country:US
Practice Address - Phone:765-482-6391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility