Basic Information
Provider Information | |||||||||
NPI: | 1710930870 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FS TENANT POOL III TRUST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DBA - THE FORUM AT DEER CREEK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 CENTRE STREET | ||||||||
Address2: |   | ||||||||
City: | NEWTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177968160 | ||||||||
FaxNumber: | 6177968375 | ||||||||
Practice Location | |||||||||
Address1: | 3001 DEER CREEK BLVD | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD | ||||||||
State: | FL | ||||||||
PostalCode: | 33442 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9546986269 | ||||||||
FaxNumber: | 9544283074 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2006 | ||||||||
LastUpdateDate: | 03/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POTTER | ||||||||
AuthorizedOfficialFirstName: | KATHERINE | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6177968387 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FS TENANT POOL III TRUST | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X |   |   | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 314000000X | SNF1162096 | FL | N |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.