Provider Demographics
NPI:1649225392
Name:FIVE STAR QUALITY CARE WI LLC
Entity Type:Organization
Organization Name:FIVE STAR QUALITY CARE WI LLC
Other - Org Name:PINE MANOR HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACKEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:617-796-8387
Mailing Address - Street 1:400 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458
Mailing Address - Country:US
Mailing Address - Phone:617-796-8387
Mailing Address - Fax:617-796-8375
Practice Address - Street 1:1625 E MAIN ST
Practice Address - Street 2:VILLAGE OF EMBARRASS
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-9236
Practice Address - Country:US
Practice Address - Phone:715-823-3135
Practice Address - Fax:715-823-1313
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR QUALITY CARE WI LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3052314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21054400Medicaid
525497Medicare Oscar/Certification