Provider Demographics
NPI:1497132237
Name:PREMIER ESTATES OF PAWNEE, LLC
Entity Type:Organization
Organization Name:PREMIER ESTATES OF PAWNEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:SHAYNE
Authorized Official - Last Name:BENCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-758-4745
Mailing Address - Street 1:5265 OFFICE PARK BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-3441
Mailing Address - Country:US
Mailing Address - Phone:941-758-4745
Mailing Address - Fax:941-751-2135
Practice Address - Street 1:438 12TH ST
Practice Address - Street 2:
Practice Address - City:PAWNEE CITY
Practice Address - State:NE
Practice Address - Zip Code:68420-3589
Practice Address - Country:US
Practice Address - Phone:402-852-2975
Practice Address - Fax:402-852-2979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100265081-00Medicaid
NE100265081-00Medicaid