Provider Demographics
NPI:1558317180
Name:FIVE STAR REMINGTON CLUB LLC
Entity Type:Organization
Organization Name:FIVE STAR REMINGTON CLUB LLC
Other - Org Name:REMINGTON CLUB HEALTH CENTER
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 1:16915 HIERBA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2681
Mailing Address - Country:US
Mailing Address - Phone:858-673-6300
Mailing Address - Fax:858-673-6318
Practice Address - Street 1:16915 HIERBA DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2688
Practice Address - Country:US
Practice Address - Phone:858-673-6300
Practice Address - Fax:858-673-6318
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR REMINGTON CLUB LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374601200310400000X
CA080000303314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555296Medicare Oscar/Certification