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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
314000000X0809MAY Nursing & Custodial Care FacilitiesSkilled Nursing Facility 

ID Information
IDTypeStateIssuerDescription
110089065A05MA MEDICAID


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