=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851689020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIVE STAR QUALITY CARE-NORTH CAROLINA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2011
-----------------------------------------------------
Last Update Date | 07/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13180 DORMAN RD
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28134-9016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-540-0155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 CENTRE ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02458-2094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | PAUL HOAGLAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-796-8387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------