Healthcare Provider Details

I. General information

NPI: 1982885406
Provider Name (Legal Business Name): 11 DAIRY LANE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 DAIRY LN
FREDERICKSBURG VA
22405-2663
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 540-371-9414
  • Fax: 540-371-4501
Mailing address:
  • Phone: 610-925-4436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2735
License Number StateVA

VIII. Authorized Official

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