=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619921277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANTERBURY OF SHEPHERDSTOWN, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 MADDEX DR
-----------------------------------------------------
City | SHEPHERDSTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25443-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-876-9422
-----------------------------------------------------
Fax | 304-876-6869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E STATE ST
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-925-4436
-----------------------------------------------------
Fax | 610-925-4351
-----------------------------------------------------
=====================================================
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 | 133
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------