Basic Information
| Provider Information | |||||||||
| NPI: | 1487760765 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINEY PARTNERS LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE VILLAGE OF LAUREL RUN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6375 CHAMBERSBURG RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172228350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173522721 | ||||||||
| FaxNumber: | 7173522142 | ||||||||
| Practice Location | |||||||||
| Address1: | 6375 CHAMBERSBURG RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172228350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173522721 | ||||||||
| FaxNumber: | 7173522142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/21/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COTTLE | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7173522721 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 420102 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001805560-0001 | 05 | PA | MEDICAID |