Provider Demographics
NPI:1447816350
Name:WATERVIEW SHORES ASSISTED LIVING LLC
Entity type:Organization
Organization Name:WATERVIEW SHORES ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-203-1001
Mailing Address - Street 1:8833 GROSS POINT RD STE 208
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 13TH AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1252
Practice Address - Country:US
Practice Address - Phone:218-834-0849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility