Basic Information
Provider Information | |||||||||
NPI: | 1174575625 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEDGEWOOD NURSING HOME, L.P. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WEDGEWOOD NURSING HOME | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 DRYDEN RD E | ||||||||
Address2: |   | ||||||||
City: | DRESHER | ||||||||
State: | PA | ||||||||
PostalCode: | 190251048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2154417700 | ||||||||
FaxNumber: | 2154414255 | ||||||||
Practice Location | |||||||||
Address1: | 6621 DAN DANCIGER RD | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761334905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8172926330 | ||||||||
FaxNumber: | 8173467980 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 10/30/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LICARI | ||||||||
AuthorizedOfficialFirstName: | PETER | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT OF GENERAL PARTNER | ||||||||
AuthorizedOfficialTelephone: | 2154417700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | 115374 | TX | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | 115374 | TX | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 115374 | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 004960 | 05 | TX |   | MEDICAID |