Provider Demographics
NPI:1194877001
Name:FIVE STAR QUALITY CARE - OBX OPERATOR, LLC
Entity type:Organization
Organization Name:FIVE STAR QUALITY CARE - OBX OPERATOR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-796-8387
Mailing Address - Street 1:400 CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458
Mailing Address - Country:US
Mailing Address - Phone:617-796-8160
Mailing Address - Fax:
Practice Address - Street 1:11230 BALLANTYNE TRACE COURT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-544-7220
Practice Address - Fax:704-544-7221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR QUALITY CARE - OBX OPERATOR, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-18
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-060-086310400000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7806166Medicaid