Basic Information
Provider Information | |||||||||
NPI: | 1629556188 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 1650 GALISTEO STREET OPERATIONS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CASA REAL | ||||||||
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: | 5059848313 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1650 GALISTEO ST | ||||||||
Address2: |   | ||||||||
City: | SANTA FE | ||||||||
State: | NM | ||||||||
PostalCode: | 875054747 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059848313 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2018 | ||||||||
LastUpdateDate: | 02/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERG | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 6109252254 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | NM | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.