Basic Information
| Provider Information | |||||||||
| NPI: | 1669496287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSQUEHANNA VILLAGE FACILITY OPERATIONS, LLC | ||||||||
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| OtherOrganizationName: | MANOR AT SUSQUEHANNA VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 CONCOURSE PKWY S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327516148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075711550 | ||||||||
| FaxNumber: | 4075711599 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 MEDICAL RD | ||||||||
| Address2: | |||||||||
| City: | MILLERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170611235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176924751 | ||||||||
| FaxNumber: | 7176924588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | USSERY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4075711550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1018126480001 | 05 | PA | MEDICAID |