1902857360 NPI number — GGNSC WILKES-BARRE EAST MOUNTAIN LP

Table of content: (NPI 1902857360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902857360 NPI number — GGNSC WILKES-BARRE EAST MOUNTAIN LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GGNSC WILKES-BARRE EAST MOUNTAIN LP
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:
GOLDEN LIVINGCENTER - EAST MOUNTAIN
Provider Other Organization Name Type Code:
3
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:
1902857360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E MOUNTAIN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILKES BARRE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18702-7911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-825-5894
Provider Business Mailing Address Fax Number:
570-822-2175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E MOUNTAIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702-7911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-825-5894
Provider Business Practice Location Address Fax Number:
570-822-2175
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RASMUSSEN-JONES
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
SEC. OF THE GP
Authorized Official Telephone Number:
479-201-4835

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  026502 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1015491310001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1526892 . This is a "GATEWAY HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30935 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0229 . This is a "BLUE CROSS NORTHEAST PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 101549131 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85623 . This is a "HEALTH AMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000113402 . This is a "THREE RIVERS HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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