MEDICARE: RELIANT PALMYRA HOLDINGS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311500000X	Alzheimer Center (Dementia Center)
2	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1275890618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RELIANT PALMYRA HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	3601 ISLAND AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19153-3228
Country	:	US
Telephone Number	:	215-558-3700
Fax Number	:	215-558-3701

Provider Business Practice Location Address
First Line	:	341 N RAILROAD ST
Second Line	:
City	:	PALMYRA
State	:	PA
Zip	:	17078-1328
Country	:	US
Telephone Number	:	717-838-3011
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MARC MYZAL
Credential	:
Telephone Number	:	215-558-3700

Provider Enumeration Date	:	04/23/2012
Last Update Date	:	04/23/2012

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