Healthcare Provider Details

I. General information

NPI: 1891746178
Provider Name (Legal Business Name): GGNSC ERIE WESTERN RESERVE LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 W 54TH ST
ERIE PA
16509-2620
US

IV. Provider business mailing address

1521 W 54TH ST
ERIE PA
16509-2620
US

V. Phone/Fax

Practice location:
  • Phone: 814-864-0671
  • Fax: 814-866-5681
Mailing address:
  • Phone: 814-864-0671
  • Fax: 814-866-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number490802
License Number StatePA

VIII. Authorized Official

Name: HOLLY A. RASMUSSEN-JONES
Title or Position: SEC. OF THE GP
Credential:
Phone: 479-201-4835