Provider Demographics
NPI:1851990436
Name:BV/MSTAR CALEDONIA TENANT, LLC
Entity Type:Organization
Organization Name:BV/MSTAR CALEDONIA TENANT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-595-6025
Mailing Address - Street 1:5737 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-1970
Mailing Address - Country:US
Mailing Address - Phone:262-639-6025
Mailing Address - Fax:262-639-5279
Practice Address - Street 1:5737 ERIE ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-1970
Practice Address - Country:US
Practice Address - Phone:262-639-6025
Practice Address - Fax:262-639-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)