Healthcare Provider Details

I. General information

NPI: 1508882002
Provider Name (Legal Business Name): STONERIDGE RETIREMENT LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 EAST LINCOLN AVE
MYERSTOWN PA
17067-2239
US

IV. Provider business mailing address

440 E LINCOLN AVE
MYERSTOWN PA
17067-2239
US

V. Phone/Fax

Practice location:
  • Phone: 717-866-3200
  • Fax: 717-866-7778
Mailing address:
  • Phone: 717-866-3200
  • Fax: 717-866-7778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number055702
License Number StatePA

VII. Legacy identifiers

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

# 1
IdentifierMA1007512800004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. STEVEN J. REITER
Title or Position: PRESIDENT/CEO
Credential: CPA
Phone: 717-866-3200