Healthcare Provider Details

I. General information

NPI: 1710348305
Provider Name (Legal Business Name): MAYBROOK-C WHITECLIFF OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 FREDONIA ROAD
GREENVILLE PA
16125-7911
US

IV. Provider business mailing address

110 FREDONIA ROAD
GREENVILLE PA
16125-7911
US

V. Phone/Fax

Practice location:
  • Phone: 724-588-8090
  • Fax:
Mailing address:
  • Phone: 724-588-8090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD S. JORDAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 724-588-8090