MEDICARE: 1650 GALISTEO STREET 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		NM

General Provider Information

NPI Number	:	1629556188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1650 GALISTEO STREET 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	:	505-984-8313
Fax Number	:	610-612-5327

Provider Business Practice Location Address
First Line	:	1650 GALISTEO ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4747
Country	:	US
Telephone Number	:	505-984-8313
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	MICHAEL BERG
Credential	:
Telephone Number	:	610-925-2254

Provider Enumeration Date	:	08/06/2018
Last Update Date	:	06/23/2025

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