Provider Demographics
NPI:1235185836
Name:FS TENANT POOL II TRUST
Entity Type:Organization
Organization Name:FS TENANT POOL II TRUST
Other - Org Name:PUEBLO NORTE SENIOR LIVING COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-796-8387
Mailing Address - Street 1:7100 E MESCAL ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-6126
Mailing Address - Country:US
Mailing Address - Phone:480-948-3990
Mailing Address - Fax:480-951-7389
Practice Address - Street 1:7090 E MESCAL ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6118
Practice Address - Country:US
Practice Address - Phone:480-948-3990
Practice Address - Fax:480-951-7389
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FS TENANT POOL II TRUST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZN046033310400000X
AZNCI343314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035090Medicare Oscar/Certification