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General NPI Number Information
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NPI Number | 1154502672
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Entity Type | Organization
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Legal Business Name | 1145 POQUONNOCK ROAD OPERATIONS LLC
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Dates
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Enumeration Date | 11/27/2007
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Last Update Date | 06/26/2025
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Provider Practice Location Address
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Address Line | 1145 POQUONNOCK RD
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City | GROTON
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State | CT
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Zip | 06340-4620
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Country | US
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Telephone | 860-446-9960
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Fax | 860-449-0290
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Provider Business Mailing Address
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Address Line | 101 E STATE ST
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City | KENNETT SQUARE
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State | PA
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Zip | 19348-3109
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Country | US
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Telephone | 610-925-4436
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Fax | 610-925-4351
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Authorized Official
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Title or Position | SECRETARY
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Name | MICHAEL T BERG
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Credential |
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Telephone | 610-444-6350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 1889
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 2374
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License Number State | CT
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