MEDICARE: 100 ST. CLAIRE DRIVE OPERATIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1215357728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	100 ST. CLAIRE DRIVE OPERATIONS LLC

Provider Business Mailing Address
First Line	:	101 E STATE ST
Second Line	:
City	:	KENNETT SQUARE
State	:	PA
Zip	:	19348-3109
Country	:	US
Telephone Number	:	610-444-6350
Fax Number	:	610-444-4395

Provider Business Practice Location Address
First Line	:	100 SAINT CLAIRE DR
Second Line	:
City	:	HOCKESSIN
State	:	DE
Zip	:	19707-8906
Country	:	US
Telephone Number	:	610-444-6350
Fax Number	:	610-444-4395

Authorized Official
Title or Position	:	ASSISTANT SECRETARY
Name	:	MICHAEL T. BERG
Credential	:
Telephone Number	:	505-468-4742

Provider Enumeration Date	:	04/23/2014
Last Update Date	:	10/13/2015

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