Healthcare Provider Details

I. General information

NPI: 1982886636
Provider Name (Legal Business Name): 810 SOUTH BROOM STREET OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 S BROOM ST
WILMINGTON DE
19805-4245
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 302-652-1181
  • Fax: 302-652-1483
Mailing address:
  • Phone: 610-925-4436
  • Fax: 610-925-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1070
License Number StateDE

VIII. Authorized Official

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