Healthcare Provider Details

I. General information

NPI: 1356159206
Provider Name (Legal Business Name): 1711 EAST BROAD STREET OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 E BROAD ST
HAZLETON PA
18201-5691
US

IV. Provider business mailing address

1711 E BROAD ST
HAZLETON PA
18201-5691
US

V. Phone/Fax

Practice location:
  • Phone: 570-453-5100
  • Fax: 570-453-5138
Mailing address:
  • Phone: 570-453-5100
  • Fax: 570-453-5138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: TIFFANY HOBACK
Title or Position: MANAGER
Credential:
Phone: 770-698-9040