Healthcare Provider Details

I. General information

NPI: 1649225392
Provider Name (Legal Business Name): FIVE STAR QUALITY CARE WI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E MAIN ST VILLAGE OF EMBARRASS
CLINTONVILLE WI
54929-9236
US

IV. Provider business mailing address

400 CENTRE ST
NEWTON MA
02458
US

V. Phone/Fax

Practice location:
  • Phone: 715-823-3135
  • Fax: 715-823-1313
Mailing address:
  • Phone: 617-796-8387
  • Fax: 617-796-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3052
License Number StateWI

VIII. Authorized Official

Name: BRUCE J MACKEY JR.
Title or Position: CEO
Credential:
Phone: 617-796-8387