1114929684 NPI number — FIVE STAR QUALITY CARE-NE, LLC

Table of content: (NPI 1114929684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114929684 NPI number — FIVE STAR QUALITY CARE-NE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR QUALITY CARE-NE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTENNIAL PARK RETIREMENT VILLAGE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114929684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 CENTRE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02458-2094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-796-8387
Provider Business Mailing Address Fax Number:
617-796-8375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 CENTENNIAL CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH PLATTE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69101-6586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-534-7000
Provider Business Practice Location Address Fax Number:
308-534-8216
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
POTTER
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
617-796-8387

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  47-0704192/11 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 47-0704192/00 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47-0704192/11 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47-0704192/00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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