Provider Demographics
NPI:1376652164
Name:FIVE STAR HEALTHCARE LLC
Entity Type:Organization
Organization Name:FIVE STAR HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARITES
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO BUSTAMANTE
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:702-248-4130
Mailing Address - Street 1:6140 COLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5211
Mailing Address - Country:US
Mailing Address - Phone:702-248-4130
Mailing Address - Fax:702-220-8735
Practice Address - Street 1:6140 COLEY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5211
Practice Address - Country:US
Practice Address - Phone:702-248-4130
Practice Address - Fax:702-220-8735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV540HHA-12251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002902011Medicaid
NV297081Medicare Oscar/Certification
NV002902011Medicaid