Healthcare Provider Details

I. General information

NPI: 1346422748
Provider Name (Legal Business Name): 1104 WELSH ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 WELSH RD
PHILADELPHIA PA
19115-3730
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 215-676-9191
  • Fax: 215-676-1266
Mailing address:
  • Phone: 610-925-4436
  • Fax: 610-925-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031602
License Number StatePA

VIII. Authorized Official

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