Healthcare Provider Details

I. General information

NPI: 1992284053
Provider Name (Legal Business Name): 3514 FOWLER AVENUE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

3514 N FOWLER AVE
SILVER CITY NM
88061-7210
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-3127
  • 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: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742