Provider Demographics
NPI:1760887111
Name:GLEN SAINT ANDREW LIVING COMMUNITY, LLC
Entity Type:Organization
Organization Name:GLEN SAINT ANDREW LIVING COMMUNITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-674-5454
Mailing Address - Street 1:5454 FARGO AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3210
Mailing Address - Country:US
Mailing Address - Phone:847-674-5454
Mailing Address - Fax:847-674-8311
Practice Address - Street 1:7000 N NEWARK AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4577
Practice Address - Country:US
Practice Address - Phone:847-647-8332
Practice Address - Fax:847-647-7073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherINTERNAL REVENUE SERVICE FEIN