Provider Demographics
NPI:1760400261
Name:FIVE STAR MEMORIAL WOODS LLC
Entity Type:Organization
Organization Name:FIVE STAR MEMORIAL WOODS LLC
Other - Org Name:THE FORUM AT MEMORIAL WOODS HEALTHCARE 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 1:400 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:617-796-8375
Practice Address - Street 1:777 N POST OAK RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-3800
Practice Address - Country:US
Practice Address - Phone:713-956-0732
Practice Address - Fax:713-956-0732
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR MEMORIAL WOODS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113230310400000X
TX100820310400000X
TX129232314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
455854Medicare Oscar/Certification