Provider Demographics
NPI:1629025986
Name:DARTMOUTH ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:DARTMOUTH ASSISTED LIVING, LLC
Other - Org Name:HERITAGE AT DARTMOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-925-4045
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 1:239 CROSS RD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1992
Practice Address - Country:US
Practice Address - Phone:508-992-8880
Practice Address - Fax:508-992-8884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAN/A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1905112Medicaid