Basic Information
| Provider Information | |||||||||
| NPI: | 1669463949 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY CREST NURSING HOME (LUZERNE COUNTY) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 E END BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708261011 | ||||||||
| FaxNumber: | 5708251211 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 E END BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708261011 | ||||||||
| FaxNumber: | 5708251211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5708261011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | NHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 220102 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0752275 | 05 | PA | MEDICAID |