Provider Demographics
NPI:1750337705
Name:FIVE STAR QUALITY CARE WI LLC
Entity type:Organization
Organization Name:FIVE STAR QUALITY CARE WI 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 1:1451 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-3876
Mailing Address - Country:US
Mailing Address - Phone:262-547-2123
Mailing Address - Fax:262-547-6204
Practice Address - Street 1:1451 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-3876
Practice Address - Country:US
Practice Address - Phone:262-547-2123
Practice Address - Fax:262-547-6204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR QUALITY CARE WI LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3059314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20187100Medicaid
525490Medicare Oscar/Certification