Provider Demographics
NPI:1417944612
Name:FIVE STAR QUALITY CARE-WI, LLC
Entity Type:Organization
Organization Name:FIVE STAR QUALITY CARE-WI, LLC
Other - Org Name:MITCHELL MANOR
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 1:400 CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458
Mailing Address - Country:US
Mailing Address - Phone:617-796-8387
Mailing Address - Fax:617-796-8385
Practice Address - Street 1:5301 WEST LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53219-1652
Practice Address - Country:US
Practice Address - Phone:414-615-7200
Practice Address - Fax:414-615-7260
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR QUALITY CARE-WI, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-03
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3181314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20201200Medicaid
WI525600Medicare Oscar/Certification