MEDICARE: FIVE STAR TUCSON FORUM 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	314000000X	Skilled Nursing Facility	NCI419	AZ

General Provider Information

NPI Number	:	1457304404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIVE STAR TUCSON FORUM LLC

Provider Business Mailing Address
First Line	:	2500 N ROSEMONT BLVD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-2167
Country	:	US
Telephone Number	:	520-325-4800
Fax Number	:	520-319-4076

Provider Business Practice Location Address
First Line	:	2500 N ROSEMONT BLVD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-2167
Country	:	US
Telephone Number	:	520-325-4800
Fax Number	:	520-319-4076

Authorized Official
Title or Position	:	PRESIDENT & CHIEF EXECUTIVE OFFICER
Name	:	KATHERINE E POTTER
Credential	:
Telephone Number	:	617-796-8387

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	03/28/2019

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Directions to “FIVE STAR TUCSON FORUM LLC ” Practice Location

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