Basic Information
| Provider Information | |||||||||
| NPI: | 1538546379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER ESTATES OF FREMONT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5265 OFFICE PARK BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342033441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417584745 | ||||||||
| FaxNumber: | 9417512135 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 N NYE AVE | ||||||||
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| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027271701 | ||||||||
| FaxNumber: | 4027271619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2015 | ||||||||
| LastUpdateDate: | 10/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | BENCH | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | SHAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9417584745 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100265078-00 | 05 | NE | MEDICAID |