Healthcare Provider Details

I. General information

NPI: 1518520352
Provider Name (Legal Business Name): 50 PHEASANT ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PHEASANT RD
PETERBOROUGH NH
03458-2110
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 610-925-2254
  • Fax:
Mailing address:
  • Phone: 610-925-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MICHAEL BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 610-925-2254