MEDICARE: FIVE STAR LIVING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	974	VA

General Provider Information

NPI Number	:	1386816882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIVE STAR LIVING, LLC

Provider Business Mailing Address
First Line	:	3101 STONY VALLEY DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-2658
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 STONY VALLEY DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-2658
Country	:	US
Telephone Number	:	704-301-2079
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. TAMAYA CAMPBELL
Credential	:
Telephone Number	:	704-301-2079

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	03/25/2008

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