Healthcare Provider Details

I. General information

NPI: 1942446745
Provider Name (Legal Business Name): 1543 COUNTRY CLUB ROAD MANOR OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1543 COUNTRY CLUB RD
FAIRMONT WV
26554-1306
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 304-363-2273
  • Fax:
Mailing address:
  • Phone: 610-925-4436
  • Fax: 610-347-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number506062
License Number StateWV

VIII. Authorized Official

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