Provider Demographics
NPI:1528023033
Name:FIVE STAR DESERT HARBOR LLC
Entity Type:Organization
Organization Name:FIVE STAR DESERT HARBOR LLC
Other - Org Name:THE FORUM AT DESERT HARBOR
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 1:13840 N DESERT HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3501
Mailing Address - Country:US
Mailing Address - Phone:623-972-0995
Mailing Address - Fax:623-977-5271
Practice Address - Street 1:13840 N DESERT HARBOR DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3501
Practice Address - Country:US
Practice Address - Phone:623-972-0995
Practice Address - Fax:623-977-5271
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR DESERT HARBOR LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-18
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-421314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0401890OtherBLUE CROSS BLUE SHIELD OF
AZ035201Medicare Oscar/Certification