Provider Demographics
NPI:1841245313
Name:FS TENANT POOL I TRUST
Entity type:Organization
Organization Name:FS TENANT POOL I TRUST
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 1:9547 HIGHWAY 17 NORTH
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9547 HIGHWAY 17 NORTH
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4039
Practice Address - Country:US
Practice Address - Phone:843-449-5283
Practice Address - Fax:843-497-0880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FS TENANT POOL I TRUST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF829314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0829NFMedicaid
425070Medicare Oscar/Certification