Basic Information
| Provider Information | |||||||||
| NPI: | 1750336020 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIVE STAR QUALITY CARE-COLORADO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILLOW TREE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814162407 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2050 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814162407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708749773 | ||||||||
| FaxNumber: | 9708743611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6177968387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIVE STAR QUALITY CARE-COLORADO LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1147 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 64623041 | 05 | CO | MEDICAID |