Provider Demographics
NPI:1508934829
Name:FS TENANT POOL III TRUST
Entity Type:Organization
Organization Name:FS TENANT POOL III TRUST
Other - Org Name:FORUM AT DEER CREEK
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 1:3001 DEER CREEK COUNTRY CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-8438
Mailing Address - Country:US
Mailing Address - Phone:954-698-6269
Mailing Address - Fax:954-428-3074
Practice Address - Street 1:3001 DEER CREEK COUNTRY CLUB BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-8438
Practice Address - Country:US
Practice Address - Phone:954-698-6269
Practice Address - Fax:954-428-3074
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FS TENANT POOL III TRUST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-04
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
FL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSNF1162096Medicaid
FL025348100Medicaid
105691Medicare Oscar/Certification
105691Medicare Oscar/Certification