Healthcare Provider Details

I. General information

NPI: 1730668880
Provider Name (Legal Business Name): 419 HARDING STREET OPERATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 HARDING ST
CLAYTON NM
88415-3323
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 575-374-2353
  • 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

VIII. Authorized Official

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