Basic Information
| Provider Information | |||||||||
| NPI: | 1134607690 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 803 HACIENDA LANE OPERATIONS LLC | ||||||||
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| OtherOrganizationName: | BLOOMFIELD NURSING AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109252254 | ||||||||
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| Practice Location | |||||||||
| Address1: | 803 HACIENDA LN | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874135109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109252254 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2018 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6109252254 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NM | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.