1760400261 NPI number — FIVE STAR MEMORIAL WOODS LLC

Table of content: MICHAEL COFFEY LMP, LMT (NPI 1033562368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760400261 NPI number — FIVE STAR MEMORIAL WOODS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR MEMORIAL WOODS 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:
THE FORUM AT MEMORIAL WOODS HEALTHCARE CENTER
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:
1760400261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 CENTRE ST
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:
777 N POST OAK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77024-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-956-0732
Provider Business Practice Location Address Fax Number:
713-956-0732
Provider Enumeration Date:
07/17/2006

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 , with the licence number:  113230 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X , with the licence number: 100820 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 129232 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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