Provider Demographics
NPI:1851803266
Name:PREMIER ESTATES 522, LLC
Entity Type:Organization
Organization Name:PREMIER ESTATES 522, LLC
Other - Org Name:PREMIER ESTATES OF CINCINNATI-RIVERSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:ADRIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANCROFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-758-4745
Mailing Address - Street 1:5115 E STATE ROAD 64
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5509
Mailing Address - Country:US
Mailing Address - Phone:941-758-4745
Mailing Address - Fax:
Practice Address - Street 1:315 LILIENTHAL ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45204-1170
Practice Address - Country:US
Practice Address - Phone:513-471-8667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0250604Medicaid