Healthcare Provider Details

I. General information

NPI: 1114018645
Provider Name (Legal Business Name): PROFESSIONAL SERVICE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 E LOOCKERMAN ST STE 3A
DOVER DE
19901-7316
US

IV. Provider business mailing address

9 E LOOCKERMAN ST STE 3A
DOVER DE
19901-7316
US

V. Phone/Fax

Practice location:
  • Phone: 901-650-4615
  • Fax: 866-207-5929
Mailing address:
  • Phone: 901-650-4615
  • Fax: 866-207-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL MCCANN
Title or Position: CEO
Credential:
Phone: 901-650-4615