Healthcare Provider Details

I. General information

NPI: 1508232414
Provider Name (Legal Business Name): 40 WHITEHALL ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 WHITEHALL RD
ROCHESTER NH
03867-3225
US

IV. Provider business mailing address

40 WHITEHALL RD
ROCHESTER NH
03867-3225
US

V. Phone/Fax

Practice location:
  • Phone: 603-332-7711
  • Fax: 603-332-7712
Mailing address:
  • Phone: 603-332-7711
  • Fax: 603-332-7712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number00000
License Number StateNH

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742