Basic Information
| Provider Information | |||||||||
| NPI: | 1679780662 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERITUS CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BROOKDALE SKYLYN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6737 W WASHINGTON ST STE 2300 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532145650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149185000 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 SKYLYN DRIVE | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645826838 | ||||||||
| FaxNumber: | 8648521270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 06/13/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP, CHIEF ADMIN. OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6155648131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | CRC856 | SC | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | CRC-0856 | SC | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | 0856 | SC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | RC0856 | 05 | SC | MEDICAID |