=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073644514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FVE EC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 09/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 MEDICAL CENTER DR
-----------------------------------------------------
City | SEWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08080-2361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-582-8700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 CENTRE ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02458-2094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-796-8387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | KATHERINE E. POTTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-796-8387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 8535701
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------