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General NPI Number Information
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NPI Number | 1154563435
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Entity Type | Organization
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Legal Business Name | FIVE STAR NORTHSHORE LLC
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Dates
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Enumeration Date | 04/01/2009
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Last Update Date | 05/13/2016
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Provider Practice Location Address
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Address Line | 10803 N PORT WASHINGTON RD
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City | MEQUON
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State | WI
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Zip | 53092-5085
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Country | US
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Telephone | 262-478-2200
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Fax |
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Provider Business Mailing Address
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Address Line | 400 CENTRE ST
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City | NEWTON
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State | MA
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Zip | 02458-2094
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT & CHIEF EXECUTIVE OFFICER
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Name | BRUCE J. MACKEY JR.
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Credential |
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Telephone | 617-796-8214
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 0013000
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License Number State | WI
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