Provider Demographics
NPI:1790738755
Name:FS TENANT POOL I TRUST
Entity Type:Organization
Organization Name:FS TENANT POOL I TRUST
Other - Org Name:SHIPLEY MANOR
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 STREET
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458
Mailing Address - Country:US
Mailing Address - Phone:617-796-8160
Mailing Address - Fax:617-796-8375
Practice Address - Street 1:2723 SHIPLEY ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810
Practice Address - Country:US
Practice Address - Phone:302-479-0111
Practice Address - Fax:302-497-5880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FS TENANT POOL I TRUST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X, 314000000X
DE1169314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000118311Medicaid
DE085031Medicare ID - Type Unspecified