Provider Demographics
NPI:1215357728
Name:100 ST. CLAIRE DRIVE OPERATIONS LLC
Entity Type:Organization
Organization Name:100 ST. CLAIRE DRIVE OPERATIONS LLC
Other - Org Name:BRACKENVILLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:610-444-6350
Mailing Address - Fax:610-444-4395
Practice Address - Street 1:100 SAINT CLAIRE DR
Practice Address - Street 2:
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-8906
Practice Address - Country:US
Practice Address - Phone:610-444-6350
Practice Address - Fax:610-444-4395
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS DE HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-23
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE085042Medicare Oscar/Certification