1891740213 NPI number — FIVE STAR QUALITY CARE IA LLC

Table of content: (NPI 1891740213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891740213 NPI number — FIVE STAR QUALITY CARE IA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR QUALITY CARE IA 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:
PRAIRIE RIDGE CARE & REHABILITATION
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:
1891740213
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:
608 PRAIRIE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDIAPOLIS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52637-7843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-394-3991
Provider Business Mailing Address Fax Number:
319-394-3041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
608 PRAIRIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDIAPOLIS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52637-7843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-394-3991
Provider Business Practice Location Address Fax Number:
319-394-3041
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:  290810 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0805382 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com