Healthcare Provider Details

I. General information

NPI: 1275556383
Provider Name (Legal Business Name): 2900 TWELFTH STREET NORTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 12TH ST N
NAPLES FL
34103-4528
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 239-261-2554
  • Fax: 239-261-4540
Mailing address:
  • Phone: 505-468-4742
  • Fax: 505-468-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF 12840962
License Number StateFL

VIII. Authorized Official

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