Provider Demographics
NPI:1891740213
Name:FIVE STAR QUALITY CARE IA LLC
Entity Type:Organization
Organization Name:FIVE STAR QUALITY CARE IA LLC
Other - Org Name:PRAIRIE RIDGE CARE & REHABILITATION
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 1:608 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:MEDIAPOLIS
Mailing Address - State:IA
Mailing Address - Zip Code:52637-7843
Mailing Address - Country:US
Mailing Address - Phone:319-394-3991
Mailing Address - Fax:319-394-3041
Practice Address - Street 1:608 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:MEDIAPOLIS
Practice Address - State:IA
Practice Address - Zip Code:52637-7843
Practice Address - Country:US
Practice Address - Phone:319-394-3991
Practice Address - Fax:319-394-3041
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR QUALITY CARE IA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN290810314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0805382Medicaid
IA165220Medicare Oscar/Certification