Provider Demographics
NPI:1427230739
Name:1526 LOMBARD STREET OPERATIONS LLC
Entity Type:Organization
Organization Name:1526 LOMBARD STREET OPERATIONS LLC
Other - Org Name:POWERBACK REHABILITATION 1526 LOMBARD STREET
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:610-925-2009
Mailing Address - Fax:610-347-4098
Practice Address - Street 1:1526 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1625
Practice Address - Country:US
Practice Address - Phone:215-546-6960
Practice Address - Fax:215-732-7451
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS PA HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-28
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA200402314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025711460001Medicaid
PA1025711460001Medicaid