Basic Information
| Provider Information | |||||||||
| NPI: | 1508919101 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIVE STAR QUALITY CARE - OBX OPERATOR, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FOREST HEIGHTS SENIOR LIVING COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 CENTRE STREET | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177968387 | ||||||||
| FaxNumber: | 6177968385 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 POLO RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367227118 | ||||||||
| FaxNumber: | 3367229785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6177968387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIVE STAR QUALITY CARE - OBX OPERATOR, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7806153 | 05 | NC | MEDICAID |