Basic Information
Provider Information | |||||||||
NPI: | 1952583775 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 61 COOPER STREET OPERATIONS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HERITAGE HALL WEST | ||||||||
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: | 6109254351 | ||||||||
Practice Location | |||||||||
Address1: | 61 COOPER ST | ||||||||
Address2: |   | ||||||||
City: | AGAWAM | ||||||||
State: | MA | ||||||||
PostalCode: | 010012149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137868000 | ||||||||
FaxNumber: | 4137865066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2007 | ||||||||
LastUpdateDate: | 07/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DROPESKEY | ||||||||
AuthorizedOfficialFirstName: | JANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CORPORATE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6109254231 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0809 | MA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 110089065A | 05 | MA |   | MEDICAID |