Provider Demographics
NPI:1811942881
Name:FIVE STAR BROOKSIDE LLC
Entity type:Organization
Organization Name:FIVE STAR BROOKSIDE 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 1:200 BROOKSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243
Mailing Address - Country:US
Mailing Address - Phone:502-245-3048
Mailing Address - Fax:502-244-6327
Practice Address - Street 1:200 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1277
Practice Address - Country:US
Practice Address - Phone:502-245-3048
Practice Address - Fax:502-244-6327
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR BROOKSIDE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100551314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100122850Medicaid
KY185194Medicare Oscar/Certification