Provider Demographics
NPI:1023728805
Name:136 DONAHOE MANOR ROAD OPERATIONS LLC
Entity type:Organization
Organization Name:136 DONAHOE MANOR ROAD OPERATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP AND 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:505-468-4742
Mailing Address - Fax:610-444-4963
Practice Address - Street 1:136 DONAHUE MANOR RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522-9728
Practice Address - Country:US
Practice Address - Phone:505-468-4742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS PM PA OPERATIONS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-01
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA395221OtherMCR