Healthcare Provider Details

I. General information

NPI: 1760544100
Provider Name (Legal Business Name): WATERVILLE SNF OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 COOL ST
WATERVILLE ME
04901-5221
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-0721
  • Fax: 207-877-2287
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 Number36217
License Number StateME

VIII. Authorized Official

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