Provider Demographics
NPI:1053561704
Name:22 TUCK ROAD OPERATIONS LLC
Entity type:Organization
Organization Name:22 TUCK ROAD 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:505-468-4742
Mailing Address - Street 1:22 TUCK RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03842-1225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 TUCK RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:NH
Practice Address - Zip Code:03842-1225
Practice Address - Country:US
Practice Address - Phone:603-926-4551
Practice Address - Fax:603-929-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03405314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30106737Medicaid
NH305055Medicare Oscar/Certification