Basic Information
| Provider Information | |||||||||
| NPI: | 1851573174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 1700 PINE STREET OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORRITON SQUARE NURSING AND REHABILITATION CENTER | ||||||||
| 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: | 1700 PINE ST | ||||||||
| Address2: | |||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194013040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102397100 | ||||||||
| FaxNumber: | 6102776239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684742 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 068202 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1025717090001 | 05 | PA | MEDICAID |