Healthcare Provider Details

I. General information

NPI: 1790783017
Provider Name (Legal Business Name): HOME FOR THE AGED OF THE LITTLE SISTERS OF THE POOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ADAMS AVE
SCRANTON PA
18509-1515
US

IV. Provider business mailing address

2500 ADAMS AVE
SCRANTON PA
18509-1515
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-4065
  • Fax: 570-343-8913
Mailing address:
  • Phone: 570-343-4065
  • Fax: 570-343-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number860302
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0007509960001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: CHARLES PATRICIA MISTRETTA
Title or Position: ADMINISTRATOR
Credential: LSP
Phone: 570-343-4065