Basic Information
| Provider Information | |||||||||
| NPI: | 1447245337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHUMBERLAND COUNTY MOUNTAIN VIEW MANOR NURSING & REHAB CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MOUNTAIN VIEW MANOR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 TREVORTON RD | ||||||||
| Address2: | |||||||||
| City: | COAL TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178669405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706444400 | ||||||||
| FaxNumber: | 5706444403 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 TREVORTON RD | ||||||||
| Address2: | |||||||||
| City: | COAL TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178669405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706444400 | ||||||||
| FaxNumber: | 5706444403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 04/20/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHAKLOS | ||||||||
| AuthorizedOfficialFirstName: | MARY ANN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5706444406 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NURSING HOME ADMINIS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 390302 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1007378070003 | 05 | PA | MEDICAID |