Provider Demographics
NPI:1265587794
Name:NEWBERRY OPERATOR LLC
Entity type:Organization
Organization Name:NEWBERRY OPERATOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-429-8062
Mailing Address - Street 1:7400 NEW LA GRANGE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4870
Mailing Address - Country:US
Mailing Address - Phone:502-429-8062
Mailing Address - Fax:502-429-0650
Practice Address - Street 1:1330 KINARD ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-3038
Practice Address - Country:US
Practice Address - Phone:803-276-2601
Practice Address - Fax:803-276-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCRC-1250310400000X
SCNCF-234314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC425035Medicare Oscar/Certification
SC446550Medicaid