Healthcare Provider Details

I. General information

NPI: 1932430998
Provider Name (Legal Business Name): LLEWELLYN'S LTC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703B MAIN ST
AVOCA PA
18641
US

IV. Provider business mailing address

703 B MAIN ST
AVOCA PA
18641
US

V. Phone/Fax

Practice location:
  • Phone: 570-237-8000
  • Fax:
Mailing address:
  • Phone: 570-457-2221
  • Fax: 570-457-3224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPP411400L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0017030320001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. JOSEPH ROBERT DESANTO
Title or Position: PRESIDENT
Credential:
Phone: 570-457-2221