Healthcare Provider Details

I. General information

NPI: 1760841167
Provider Name (Legal Business Name): PASSAGE VILLAGE OF LAUREL RUN OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6375 CHAMBERSBURG RD
FAYETTEVILLE PA
17222-8350
US

IV. Provider business mailing address

6375 CHAMBERSBURG RD
FAYETTEVILLE PA
17222-8350
US

V. Phone/Fax

Practice location:
  • Phone: 717-352-2721
  • Fax: 717-352-2142
Mailing address:
  • Phone: 717-352-2721
  • Fax: 717-352-2142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number420102
License Number StatePA

VIII. Authorized Official

Name: MR. LARRY COTTLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 717-352-2721