Provider Demographics
NPI:1346274370
Name:KAUFMAN STREET WV LLC
Entity Type:Organization
Organization Name:KAUFMAN STREET WV LLC
Other - Org Name:ARBORS AT FAIRMONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-8119
Mailing Address - Street 1:111 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2903
Mailing Address - Country:US
Mailing Address - Phone:414-908-8119
Mailing Address - Fax:414-908-7105
Practice Address - Street 1:130 KAUFMAN DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2179
Practice Address - Country:US
Practice Address - Phone:304-363-5633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0004212000Medicaid
WV0004212000Medicaid