Healthcare Provider Details

I. General information

NPI: 1528023033
Provider Name (Legal Business Name): FIVE STAR DESERT HARBOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13840 N DESERT HARBOR DR
PEORIA AZ
85381-3501
US

IV. Provider business mailing address

13840 N DESERT HARBOR DR
PEORIA AZ
85381-3501
US

V. Phone/Fax

Practice location:
  • Phone: 623-972-0995
  • Fax: 623-977-5271
Mailing address:
  • Phone: 623-972-0995
  • Fax: 623-977-5271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCI-421
License Number StateAZ

VIII. Authorized Official

Name: KATHERINE E POTTER
Title or Position: PRESIDENT & CHIEF EXECUTIVE OFFICER
Credential:
Phone: 617-796-8387