1013300789 NPI number — PREMIER ESTATES OF CRETE, LLC

Table of content: (NPI 1013300789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013300789 NPI number — PREMIER ESTATES OF CRETE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER ESTATES OF CRETE, 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:
Provider Other Organization Name Type Code:
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:
1013300789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5265 OFFICE PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34203-3441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-758-4745
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 E 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRETE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68333-3108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-826-4325
Provider Business Practice Location Address Fax Number:
402-826-4654
Provider Enumeration Date:
03/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BENCH
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
SHAYNE
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
941-758-4745

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100265077-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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