Basic Information
| Provider Information | |||||||||
| NPI: | 1851803266 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER ESTATES 522, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER ESTATES OF CINCINNATI-RIVERSIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5115 E STATE ROAD 64 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342085509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417584745 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 315 LILIENTHAL ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452041170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134718667 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2017 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | BANCROFT | ||||||||
| AuthorizedOfficialFirstName: | ADRIANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | RECEPTIONIST | ||||||||
| AuthorizedOfficialTelephone: | 9417584745 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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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 | 0250604 | 05 | OH | MEDICAID |