=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063763464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SR-73 AND LAKESIDE AVENUE OPERATIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2012
-----------------------------------------------------
Last Update Date | 03/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 ROUTE 73
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-9573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-925-2009
-----------------------------------------------------
Fax | 610-347-4098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E STATE ST
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-925-2009
-----------------------------------------------------
Fax | 610-347-4098
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE MANAGER
-----------------------------------------------------
Name | JANE DROPESKEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-925-4231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------