Basic Information
| Provider Information | |||||||||
| NPI: | 1619274545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 3330 WILKENS AVENUE OPERATIONS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254436 | ||||||||
| FaxNumber: | 6103474099 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 WILKENS AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212294610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105251544 | ||||||||
| FaxNumber: | 4106464779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2011 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 30008 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 314000000X | 30008 | MD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 420461100 | 05 | MD | MEDICAID |