Provider Demographics
NPI:1417673906
Name:1100 EAST NELSON ROAD OPERATIONS LLC
Entity Type:Organization
Organization Name:1100 EAST NELSON ROAD OPERATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST 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:JD
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:
Practice Address - Street 1:1100 E NELSON RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2360
Practice Address - Country:US
Practice Address - Phone:509-765-6788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4114427Medicaid
WA50-5320OtherMEDICARE