Provider Demographics
NPI:1467497164
Name:FIVE STAR SEVERNA PARK LLC
Entity Type:Organization
Organization Name:FIVE STAR SEVERNA PARK LLC
Other - Org Name:HEARTLANDS AT SEVERNA PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACKEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:617-796-8214
Mailing Address - Street 1:400 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-2094
Mailing Address - Country:US
Mailing Address - Phone:617-796-8387
Mailing Address - Fax:617-796-8385
Practice Address - Street 1:715 BENFIELD RD
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2210
Practice Address - Country:US
Practice Address - Phone:410-729-1600
Practice Address - Fax:410-729-2313
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR SEVERNA PARK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-17
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02AL020310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility