Healthcare Provider Details

I. General information

NPI: 1063878767
Provider Name (Legal Business Name): PREMIER ESTATES 504, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E J AVE
GRUNDY CENTER IA
50638-2031
US

IV. Provider business mailing address

5115 E STATE ROAD 64
BRADENTON FL
34208-5509
US

V. Phone/Fax

Practice location:
  • Phone: 319-824-5436
  • Fax: 319-824-5808
Mailing address:
  • Phone: 941-758-4745
  • Fax: 941-751-2135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number380377
License Number StateIA

VIII. Authorized Official

Name: JAMIE CULP
Title or Position: CONTROLLER
Credential:
Phone: 941-758-4745