Basic Information
| Provider Information | |||||||||
| NPI: | 1760400261 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIVE STAR MEMORIAL WOODS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE FORUM AT MEMORIAL WOODS HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024582094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177968387 | ||||||||
| FaxNumber: | 6177968375 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 N POST OAK RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770243800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139560732 | ||||||||
| FaxNumber: | 7139560732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6177968387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIVE STAR MEMORIAL WOODS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 113230 | TX | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | 100820 | TX | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | 129232 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.