Provider Demographics
NPI:1649226028
Name:FIVE STAR MONTEBELLO LLC
Entity type:Organization
Organization Name:FIVE STAR MONTEBELLO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:10500 ACADEMY RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7306
Mailing Address - Country:US
Mailing Address - Phone:505-294-9944
Mailing Address - Fax:505-294-1808
Practice Address - Street 1:10500 ACADEMY RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-7306
Practice Address - Country:US
Practice Address - Phone:505-294-9944
Practice Address - Fax:505-294-1808
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR MONTEBELLO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001310400000X
1079314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
325048Medicare Oscar/Certification