Provider Demographics
NPI:1952813289
Name:PREMIER ESTATES 520, LLC
Entity Type:Organization
Organization Name:PREMIER ESTATES 520, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CASSIDY
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 1:4400 VANNEST AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-2770
Practice Address - Country:US
Practice Address - Phone:513-422-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0284516Medicaid
OH0250543Medicaid