Basic Information
Provider Information | |||||||||
NPI: | 1154376515 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FIVE STAR OVERLAND PARK LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE FORUM AT OVERLAND PARK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 CENTRE ST | ||||||||
Address2: |   | ||||||||
City: | NEWTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177968387 | ||||||||
FaxNumber: | 6177968375 | ||||||||
Practice Location | |||||||||
Address1: | 3501 WEST 95TH ST | ||||||||
Address2: |   | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 662062063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136484500 | ||||||||
FaxNumber: | 9136486144 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2006 | ||||||||
LastUpdateDate: | 03/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POTTER | ||||||||
AuthorizedOfficialFirstName: | KATHERINE | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6177968387 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FIVE STAR OVERLAND PARK LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | N046033 | KS | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 314000000X | N046033 | KS | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.