Healthcare Provider Details

I. General information

NPI: 1669654489
Provider Name (Legal Business Name): 4901 NORTH MAIN STREET OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 N MAIN ST
FALL RIVER MA
02720-2080
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 508-675-1001
  • Fax: 508-675-1088
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 Number0951
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110088824A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

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