Basic Information
Provider Information | |||||||||
NPI: | 1275675498 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMERITUS CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BROOKDALE CHUBBUCK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6737 W WASHINGTON ST STE 2300 | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532145650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4149185000 | ||||||||
FaxNumber: | 2063577292 | ||||||||
Practice Location | |||||||||
Address1: | 4080 HAWTHORNE ROAD | ||||||||
Address2: |   | ||||||||
City: | CHUBBUCK | ||||||||
State: | ID | ||||||||
PostalCode: | 83202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082373000 | ||||||||
FaxNumber: | 2082376024 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2007 | ||||||||
LastUpdateDate: | 07/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LESKOWICZ | ||||||||
AuthorizedOfficialFirstName: | JOANNE | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4149185000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BROOKDALE SENIOR LIVING INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | RC-772 | ID | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | M8054377 | 05 | ID |   | MEDICAID | 805437700 | 05 | ID |   | MEDICAID |