1811191943 NPI number — FIVE STAR GRANITE GATE, LLC

Table of content: (NPI 1811191943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811191943 NPI number — FIVE STAR GRANITE GATE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR GRANITE GATE, 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:
6
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:
1811191943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 CENTRE STREET
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-796-8387
Provider Business Mailing Address Fax Number:
617-796-8385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 NORTH US HIGHWAY 89
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-771-8200
Provider Business Practice Location Address Fax Number:
928-771-8213
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOAGLAND
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
617-796-8292

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ALC-6120 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ALC-6120 . This is a "ASSISTED LIVING LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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