=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366407876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIVE STAR CROSSING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2006
-----------------------------------------------------
Last Update Date | 03/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8505 WOODFIELD CROSSING BLVD
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46240-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-257-7406
-----------------------------------------------------
Fax | 317-466-3094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 CENTRE ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-796-8387
-----------------------------------------------------
Fax | 617-796-8375
-----------------------------------------------------
=====================================================
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 | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 10-000191-2
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------