1336194612 NPI number — FIVE STAR QUALITY CARE-MI LLC

Table of content: (NPI 1336194612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336194612 NPI number — FIVE STAR QUALITY CARE-MI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR QUALITY CARE-MI 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:
FARMINGTON HEALTH CARE 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:
1336194612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 CENTRE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02458-2094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-796-8387
Provider Business Mailing Address Fax Number:
617-796-8375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34225 GRAND RIVER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48335-3440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-477-7373
Provider Business Practice Location Address Fax Number:
248-477-2888
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACKEY
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
617-796-8387

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  634450 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4292558/60 & 42925 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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