Provider Demographics
NPI:1053715995
Name:THE ESTATES OF SPANISH LAKE, LLC
Entity type:Organization
Organization Name:THE ESTATES OF SPANISH LAKE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TUVIYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SPECTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-322-0387
Mailing Address - Street 1:5940 W TOUHY AVE
Mailing Address - Street 2:STE 350
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-4638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 PRIGGE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-3543
Practice Address - Country:US
Practice Address - Phone:610-828-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
265776Medicare Oscar/Certification