Basic Information
Provider Information | |||||||||
NPI: | 1962837138 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RELIANT PROSPECT PARK, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROSPECT PARK HEALTH AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3601 ISLAND AVE | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191533228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2155583700 | ||||||||
FaxNumber: | 2155583701 | ||||||||
Practice Location | |||||||||
Address1: | 815 CHESTER PIKE | ||||||||
Address2: |   | ||||||||
City: | PROSPECT PARK | ||||||||
State: | PA | ||||||||
PostalCode: | 190762322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6105866262 | ||||||||
FaxNumber: | 6105862262 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2013 | ||||||||
LastUpdateDate: | 09/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCIOLE | ||||||||
AuthorizedOfficialFirstName: | ANTHONY | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2155583700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 162502 | PA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.