Basic Information
| Provider Information | |||||||||
| NPI: | 1760423065 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OP HAZELTON, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE MANOR AT ST. LUKE 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: | 1711 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | HAZLETON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182015691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704535100 | ||||||||
| FaxNumber: | 5704535138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONTE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4075711550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 195202 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1012273990001 | 05 | PA | MEDICAID |