Healthcare Provider Details

I. General information

NPI: 1093701047
Provider Name (Legal Business Name): BUCKTAIL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 PINE ST
RENOVO PA
17764-1618
US

IV. Provider business mailing address

1001 PINE ST
RENOVO PA
17764-1618
US

V. Phone/Fax

Practice location:
  • Phone: 570-923-1000
  • Fax: 570-923-1812
Mailing address:
  • Phone: 570-923-1000
  • Fax: 570-923-1812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number549602
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number549602
License Number StatePA

VIII. Authorized Official

Name: GARY DAILEY
Title or Position: ACCOUNTANT
Credential:
Phone: 570-923-1000