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NPI Code Detail

MEDICARE: 3514 FOWLER AVENUE OPERATIONS LLC

MEDICARE: 3514 FOWLER AVENUE 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
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1992284053
Entity Type Code : Organization
Provider Name (Legal Business Name) : 3514 FOWLER AVENUE 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 : 610-925-2254
Fax Number :
Provider Business Practice Location Address
First Line : 3514 N FOWLER AVE
Second Line :
City : SILVER CITY
State : NM
Zip : 88061-7210
Country : US
Telephone Number : 575-388-3127
Fax Number :
Authorized Official
Title or Position : ASSISTANT SECRETARY
Name : MICHAEL BERG
Credential :
Telephone Number : 505-468-4742
Provider Enumeration Date : 08/09/2018
Last Update Date : 08/09/2018

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