Provider Demographics
NPI:1982991279
Name:FIVE STAR ALTERNATIVE CARE NURSING CO
Entity Type:Organization
Organization Name:FIVE STAR ALTERNATIVE CARE NURSING CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAVNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-814-0056
Mailing Address - Street 1:725 WILDWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:PALO
Mailing Address - State:CA
Mailing Address - Zip Code:94303
Mailing Address - Country:US
Mailing Address - Phone:650-814-0056
Mailing Address - Fax:650-739-0659
Practice Address - Street 1:6617 STRATFORD ROAD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:650-814-0056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR ALTERNATIVE CARE NURSING CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1040251-6-AFC302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization