Basic Information
| Provider Information | |||||||||
| NPI: | 1649225392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIVE STAR QUALITY CARE WI LLC | ||||||||
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| OtherOrganizationName: | PINE MANOR HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177968387 | ||||||||
| FaxNumber: | 6177968375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 E MAIN ST | ||||||||
| Address2: | VILLAGE OF EMBARRASS | ||||||||
| City: | CLINTONVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549299236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158233135 | ||||||||
| FaxNumber: | 7158231313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | MACKEY | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6177968387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIVE STAR QUALITY CARE WI LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3052 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 21054400 | 05 | WI | MEDICAID |