Healthcare Provider Details

I. General information

NPI: 1629125166
Provider Name (Legal Business Name): MILLCREEK MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5515 PEACH ST
ERIE PA
16509-2603
US

IV. Provider business mailing address

5515 PEACH ST
ERIE PA
16509-2603
US

V. Phone/Fax

Practice location:
  • Phone: 814-868-8252
  • Fax:
Mailing address:
  • Phone: 814-868-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number123456
License Number StatePA

VIII. Authorized Official

Name: JEANNE L MILLER
Title or Position: PT ACCT MGR
Credential:
Phone: 814-868-8252