MEDICARE: FIVE STAR QUALITY CARE WI LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	3052	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649225392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIVE STAR QUALITY CARE WI LLC

Provider Business Mailing Address
First Line	:	400 CENTRE ST
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02458
Country	:	US
Telephone Number	:	617-796-8387
Fax Number	:	617-796-8375

Provider Business Practice Location Address
First Line	:	1625 E MAIN ST
Second Line	:	VILLAGE OF EMBARRASS
City	:	CLINTONVILLE
State	:	WI
Zip	:	54929-9236
Country	:	US
Telephone Number	:	715-823-3135
Fax Number	:	715-823-1313

Authorized Official
Title or Position	:	CEO
Name	:	BRUCE J MACKEY JR.
Credential	:
Telephone Number	:	617-796-8387

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	05/19/2008

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