Basic Information
| Provider Information | |||||||||
| NPI: | 1154430189 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NANTICOKE ALTERNATIVE CARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LIFECARE AT LOFLAND PARK INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 715 E KING ST | ||||||||
| Address2: | |||||||||
| City: | SEAFORD | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199733505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026283000 | ||||||||
| FaxNumber: | 3026283714 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 E KING ST | ||||||||
| Address2: | |||||||||
| City: | SEAFORD | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199733505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026283000 | ||||||||
| FaxNumber: | 3026283714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIVENS | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3026283000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN,BS,NHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 1088 | DE | X | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 1088 | DE | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0000419711 | 05 | DE | MEDICAID | 155186 | 01 | DE | BLUE CROSS BLUE SHIELD | OTHER | 0000419646 | 05 | DE | MEDICAID | 0000444512 | 05 | DE | MEDICAID |