Healthcare Provider Details

I. General information

NPI: 1396995056
Provider Name (Legal Business Name): 290 HANOVER STREET OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 HANOVER ST
CLAREMONT NH
03743-5034
US

IV. Provider business mailing address

290 HANOVER ST
CLAREMONT NH
03743-5034
US

V. Phone/Fax

Practice location:
  • Phone: 603-542-2606
  • Fax: 617-889-0105
Mailing address:
  • Phone: 603-542-2606
  • Fax: 617-889-0105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number03404
License Number StateNH

VIII. Authorized Official

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