Provider Demographics
NPI:1285749754
Name:FIVE STAR QUALITY CARE-IN LLC
Entity type:Organization
Organization Name:FIVE STAR QUALITY CARE-IN 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 1:2455 TAMARACK TRAIL
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-1294
Mailing Address - Country:US
Mailing Address - Phone:812-336-7060
Mailing Address - Fax:812-333-8917
Practice Address - Street 1:2455 TAMARACK TRAIL
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1294
Practice Address - Country:US
Practice Address - Phone:812-336-7060
Practice Address - Fax:812-333-8917
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR QUALITY CARE-IN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-21
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155253Medicare Oscar/Certification
IN155253Medicare ID - Type Unspecified