Provider Demographics
NPI:1619265261
Name:FVE SE WILSON LLC
Entity Type:Organization
Organization Name:FVE SE WILSON LLC
Other - Org Name:PARKWOOD VILLAGE
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 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 1:1730 PARKWOOD BLVD W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3564
Practice Address - Country:US
Practice Address - Phone:252-237-9050
Practice Address - Fax:252-237-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-098-029310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility