1639124712 NPI number — FIVE STAR QUALITY CARE-WY LLC

Table of content: (NPI 1639124712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639124712 NPI number — FIVE STAR QUALITY CARE-WY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR QUALITY CARE-WY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WORLAND HEALTHCARE & REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639124712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 HOWELL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORLAND
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82401-3733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-347-4285
Provider Business Mailing Address Fax Number:
307-347-2154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 HOWELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORLAND
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82401-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-347-4285
Provider Business Practice Location Address Fax Number:
307-347-2154
Provider Enumeration Date:
05/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
POTTER
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
617-796-8387

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  06-137 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 115809100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".