Healthcare Provider Details

I. General information

NPI: 1528240090
Provider Name (Legal Business Name): 9101 SECOND AVENUE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 2ND AVE
SILVER SPRING MD
20910-2152
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 301-588-5544
  • Fax: 301-588-5547
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 Number15-006
License Number StateMD

VII. Legacy identifiers

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

# 1
Identifier413977100
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752