Basic Information
| Provider Information | |||||||||
| NPI: | 1063763464 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SR-73 AND LAKESIDE AVENUE OPERATIONS LLC | ||||||||
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| OtherOrganizationName: | POWERBACK REHABILITATION, 113 SOUTH ROUTE 73 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109252009 | ||||||||
| FaxNumber: | 6103474098 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 ROUTE 73 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080439573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109252009 | ||||||||
| FaxNumber: | 6103474098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 03/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | DROPESKEY | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6109254231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 31-5513 | 01 | NJ | MEDICARE PTAN | OTHER |