Healthcare Provider Details

I. General information

NPI: 1467069005
Provider Name (Legal Business Name): EMBASSY HEARTHSIDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WAUPELANI DR
STATE COLLEGE PA
16801-4516
US

IV. Provider business mailing address

25201 CHAGRIN BLVD
BEACHWOOD OH
44122-5600
US

V. Phone/Fax

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

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: GEORGE REPCHICK
Title or Position: PRESIDENT OF MANAGER
Credential:
Phone: 216-378-2050