1245267319 NPI number — BROADWAY CONVALESCENT CENTER, L.P.

Table of content: (NPI 1245267319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245267319 NPI number — BROADWAY CONVALESCENT CENTER, L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY CONVALESCENT CENTER, L.P.
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:
Provider Other Organization Name Type Code:
6
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:
1245267319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 DRYDEN ROAD, SUITE 2000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DRESHER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19025-1048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-441-7700
Provider Business Mailing Address Fax Number:
215-441-4255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1841 FLAMINGO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-824-5324
Provider Business Practice Location Address Fax Number:
210-824-5360
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LICARI
Authorized Official First Name:
PETER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT OF GENERAL PARTNER
Authorized Official Telephone Number:
215-441-7700

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  113793 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BN1400X , with the licence number: 120074 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: 120074 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004354 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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