Provider Demographics
NPI:1508928995
Name:KENNEBUNK OPERATIONS, LLC
Entity Type:Organization
Organization Name:KENNEBUNK OPERATIONS, LLC
Other - Org Name:RIVERRIDGE 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:610-925-4436
Mailing Address - Fax:610-925-4351
Practice Address - Street 1:3 BRAZIER LANE
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6924
Practice Address - Country:US
Practice Address - Phone:207-985-3030
Practice Address - Fax:207-985-6428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1906314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432469801Medicaid
ME432469900Medicaid
ME432469800Medicaid
ME432469900Medicaid