1710930870 NPI number — FS TENANT POOL III TRUST

Table of content: (NPI 1710930870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710930870 NPI number — FS TENANT POOL III TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FS TENANT POOL III TRUST
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:
DBA - THE FORUM AT DEER CREEK
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:
1710930870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2019
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-796-8160
Provider Business Mailing Address Fax Number:
617-796-8375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 DEER CREEK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEERFIELD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-698-6269
Provider Business Practice Location Address Fax Number:
954-428-3074
Provider Enumeration Date:
05/18/2006

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: SNF1162096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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