Healthcare Provider Details

I. General information

NPI: 1174586002
Provider Name (Legal Business Name): UNIVERSITY PARK NURSING, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WAUPELANI DRIVE
STATE COLLEGE PA
16801-4516
US

IV. Provider business mailing address

450 WAUPELANI DRIVE
STATE COLLEGE PA
16801-4516
US

V. Phone/Fax

Practice location:
  • Phone: 814-237-0630
  • Fax: 814-237-1803
Mailing address:
  • Phone: 814-237-0630
  • Fax: 814-237-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number940502
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier101188085
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier4901777625
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. PETER J LICARI
Title or Position: PRESIDENT
Credential:
Phone: 215-441-7700