Basic Information
Provider Information | |||||||||
NPI: | 1083628085 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HCF OF SWEDEN VALLEY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SWEDEN VALLEY MANOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1028 E 2ND ST | ||||||||
Address2: |   | ||||||||
City: | COUDERSPORT | ||||||||
State: | PA | ||||||||
PostalCode: | 169158306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8142747610 | ||||||||
FaxNumber: | 8142748010 | ||||||||
Practice Location | |||||||||
Address1: | 1028 E 2ND ST | ||||||||
Address2: |   | ||||||||
City: | COUDERSPORT | ||||||||
State: | PA | ||||||||
PostalCode: | 169158306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8142747610 | ||||||||
FaxNumber: | 8142748010 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2006 | ||||||||
LastUpdateDate: | 10/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STECHSCHULTE | ||||||||
AuthorizedOfficialFirstName: | RYAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR - CORPORATE COMPLIANCE | ||||||||
AuthorizedOfficialTelephone: | 4199992010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 455402 | PA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 000000099832 | 01 | PA | THREE RIVERS/UNISON | OTHER | 0019252000001 | 05 | PA |   | MEDICAID | 00926325 | 05 | NY |   | MEDICAID | 305047 | 01 | PA | ADVANTRA | OTHER | 0052 | 01 | PA | SECURITY BLUE | OTHER |