1083070783 NPI number — PREMIER ESTATES 506, LLC

Table of content: (NPI 1083070783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083070783 NPI number — PREMIER ESTATES 506, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER ESTATES 506, 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:
1083070783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5115 E STATE ROAD 64
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34208-5509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-758-4745
Provider Business Mailing Address Fax Number:
941-751-2135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3661 ROCHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52245-9271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-351-7460
Provider Business Practice Location Address Fax Number:
319-354-8428
Provider Enumeration Date:
01/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BANCROFT
Authorized Official First Name:
CASSIDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
941-758-4745

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  520052 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0800179 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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