Healthcare Provider Details

I. General information

NPI: 1215357728
Provider Name (Legal Business Name): 100 ST. CLAIRE DRIVE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SAINT CLAIRE DR
HOCKESSIN DE
19707-8906
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 610-444-6350
  • Fax: 610-444-4395
Mailing address:
  • Phone: 610-444-6350
  • Fax: 610-444-4395

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: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742