Provider Demographics
NPI:1447634266
Name:FS LEISURE PARK TENANT TRUST
Entity type:Organization
Organization Name:FS LEISURE PARK TENANT 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 1:1400 ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 ROUTE 70
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5949
Practice Address - Country:US
Practice Address - Phone:732-370-0444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FS LEISURE PARK TENANT TRUST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-10
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ315256Medicare Oscar/Certification