Provider Demographics
NPI:1528240090
Name:9101 SECOND AVENUE OPERATIONS LLC
Entity type:Organization
Organization Name:9101 SECOND AVENUE OPERATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:505-468-4752
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 1:9101 2ND AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-2152
Practice Address - Country:US
Practice Address - Phone:301-588-5544
Practice Address - Fax:301-588-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15-006314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413977100Medicaid
MD413977100Medicaid