Basic Information
| Provider Information | |||||||||
| NPI: | 1073979779 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER ESTATES 505, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PLEASANT ACRES CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5115 E STATE ROAD 64 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342085509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417584745 | ||||||||
| FaxNumber: | 9417512135 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 RAILROAD ST | ||||||||
| Address2: | |||||||||
| City: | HULL | ||||||||
| State: | IA | ||||||||
| PostalCode: | 512397413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124392758 | ||||||||
| FaxNumber: | 7124392764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2016 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | CULP | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 9417584745 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 840120 | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0800182 | 05 | IA | MEDICAID |