Healthcare Provider Details

I. General information

NPI: 1922816966
Provider Name (Legal Business Name): 69 COTTAGE ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 COTTAGE RD
MIFFLIN PA
17058-7030
US

IV. Provider business mailing address

69 COTTAGE RD
MIFFLIN PA
17058-7030
US

V. Phone/Fax

Practice location:
  • Phone: 717-436-8921
  • Fax: 717-436-9165
Mailing address:
  • Phone: 717-436-8921
  • Fax: 717-436-9165

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