MEDICARE: FIVE STAR DESERT HARBOR 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	NCI-421	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0401890	OTHER	AZ	BLUE CROSS BLUE SHIELD OF

General Provider Information

NPI Number	:	1528023033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIVE STAR DESERT HARBOR LLC

Provider Business Mailing Address
First Line	:	13840 N DESERT HARBOR DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-3501
Country	:	US
Telephone Number	:	623-972-0995
Fax Number	:	623-977-5271

Provider Business Practice Location Address
First Line	:	13840 N DESERT HARBOR DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-3501
Country	:	US
Telephone Number	:	623-972-0995
Fax Number	:	623-977-5271

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

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	03/28/2019

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