Healthcare Provider Details

I. General information

NPI: 1477735793
Provider Name (Legal Business Name): 225 EVERGREEN ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 EVERGREEN RD
POTTSTOWN PA
19464-3143
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 610-323-1800
  • Fax: 610-323-7914
Mailing address:
  • Phone: 610-925-4436
  • Fax: 610-925-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number233702
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1025719050001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

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