Basic Information
Provider Information | |||||||||
NPI: | 1275841322 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 56 WEST FREDERICK STREET OPERATIONS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GLADE VALLEY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 E STATE ST | ||||||||
Address2: |   | ||||||||
City: | KENNETT SQUARE | ||||||||
State: | PA | ||||||||
PostalCode: | 193483109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109254436 | ||||||||
FaxNumber: | 6103474099 | ||||||||
Practice Location | |||||||||
Address1: | 56 W FREDERICK ST | ||||||||
Address2: |   | ||||||||
City: | WALKERSVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 217938254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018984300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2010 | ||||||||
LastUpdateDate: | 01/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERG | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 5054684752 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 10-015 | MD | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 430910300 | 05 | MD |   | MEDICAID | 556219800 | 05 | MD |   | MEDICAID |