1679252118 NPI number — MILLCREEK MANOR

Table of content: (NPI 1679252118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679252118 NPI number — MILLCREEK MANOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLCREEK MANOR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLINICAL PRACTICE OF LECOM INSTITUTE FOR SUCCESSFUL LIVING
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679252118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5535 PEACH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16509-2603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-881-5234
Provider Business Mailing Address Fax Number:
814-871-4545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 PEACH ST STE 3400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16509-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-868-2200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2023

Additional Information

Authorized Official

Authorized Official Last Name:
TOPEL
Authorized Official First Name:
OLIVIA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
814-881-5234

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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