Basic Information
| Provider Information | |||||||||
| NPI: | 1417971045 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH STRABANE FACILITY OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CONSULATE HEALTH CARE OF NORTH STRABANE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 800 CONCOURSE PKWY S | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327516152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075711550 | ||||||||
| FaxNumber: | 4075711599 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 TANDEM VILLAGE RD | ||||||||
| Address2: | |||||||||
| City: | CANONSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153172382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247439000 | ||||||||
| FaxNumber: | 7247430188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/11/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | USSERY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4075711550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1018132700001 | 05 | PA | MEDICAID |