Basic Information
| Provider Information | |||||||||
| NPI: | 1043656630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WG FALMOUTH SH II, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ATRIA WOODBRIAR PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 401 S 4TH ST STE 1900 | ||||||||
| Address2: | ATTN: LEGAL DEPT. | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402024436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027794700 | ||||||||
| FaxNumber: | 5027794749 | ||||||||
| Practice Location | |||||||||
| Address1: | 389 GIFFORD ST | ||||||||
| Address2: | |||||||||
| City: | FALMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084955500 | ||||||||
| FaxNumber: | 5084959515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2013 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUDSON | ||||||||
| AuthorizedOfficialFirstName: | W | ||||||||
| AuthorizedOfficialMiddleName: | BRYAN | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 5027794700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | APPLIED FOR | MA | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.