Healthcare Provider Details

I. General information

NPI: 1649226028
Provider Name (Legal Business Name): FIVE STAR MONTEBELLO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 ACADEMY RD NE
ALBUQUERQUE NM
87111-7306
US

IV. Provider business mailing address

10500 ACADEMY RD NE
ALBUQUERQUE NM
87111-7306
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-9944
  • Fax: 505-294-1808
Mailing address:
  • Phone: 505-294-9944
  • Fax: 505-294-1808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2001
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1079
License Number State

VIII. Authorized Official

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