Healthcare Provider Details

I. General information

NPI: 1275841322
Provider Name (Legal Business Name): 56 WEST FREDERICK STREET OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 W FREDERICK ST
WALKERSVILLE MD
21793-8254
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 301-898-4300
  • Fax:
Mailing address:
  • Phone: 610-925-4436
  • Fax: 610-347-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10-015
License Number StateMD

VIII. Authorized Official

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