Basic Information
| Provider Information | |||||||||
| NPI: | 1295936813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERITUS PROPERTIES XIV, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKDALE EDDY POND WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6737 W WASHINGTON ST, SUITE 2300 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532145650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149185000 | ||||||||
| FaxNumber: | 5088322861 | ||||||||
| Practice Location | |||||||||
| Address1: | 669 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088324458 | ||||||||
| FaxNumber: | 5088322861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP, CHIEF ADMIN. OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6155648131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | EOEA CERTIFICATE ALF | MA | N | Managed Care Organizations | Exclusive Provider Organization | 310400000X | MA | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 1905941 | 05 | MA | MEDICAID | 1900455 | 05 | MA | MEDICAID |