Provider Demographics
NPI:1366498719
Name:FS TENANT POOL I TRUST
Entity Type:Organization
Organization Name:FS TENANT POOL I TRUST
Other - Org Name:MILLCROFT RETIREMENT COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRINE
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 1:255 POSSUM PARK RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-3877
Mailing Address - Country:US
Mailing Address - Phone:302-366-0160
Mailing Address - Fax:302-366-7634
Practice Address - Street 1:255 POSSUM PARK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-3877
Practice Address - Country:US
Practice Address - Phone:302-366-0160
Practice Address - Fax:302-366-7634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FS TENANT POOL I TRUST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1307310400000X
DE1099314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001188711Medicaid
085021Medicare Oscar/Certification