Healthcare Provider Details

I. General information

NPI: 1467016105
Provider Name (Legal Business Name): 400 VISION DRIVE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 VISION DR
ASHEBORO NC
27203-3855
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 336-672-5450
  • Fax:
Mailing address:
  • Phone: 610-444-6350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 505-468-4742