Basic Information
| Provider Information | |||||||||
| NPI: | 1689827487 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIVE STAR QUALITY CARE- NORTH CAROLINA, LLC | ||||||||
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| OtherOrganizationName: | THE HAVENS IN THE VILLAGE AT CAROLINA PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 CENTRE STREET | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177968160 | ||||||||
| FaxNumber: | 6177968375 | ||||||||
| Practice Location | |||||||||
| Address1: | 13180 DORMAN ROAD | ||||||||
| Address2: | |||||||||
| City: | PINEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045400155 | ||||||||
| FaxNumber: | 7045408007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 06/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | MACKEY | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6177968214 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIVE STAR QUALITY CARE- NORTH CAROLINA,LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | HAL-060-107 | NC | Y | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |
No ID Information.