Healthcare Provider Details

I. General information

NPI: 1154502672
Provider Name (Legal Business Name): 1145 POQUONNOCK ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 POQUONNOCK RD
GROTON CT
06340-4620
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 860-446-9960
  • Fax: 860-449-0290
Mailing address:
  • Phone: 610-925-4436
  • Fax: 610-925-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number1889
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2374
License Number StateCT

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: SECRETARY
Credential:
Phone: 610-444-6350