Healthcare Provider Details

I. General information

NPI: 1740280890
Provider Name (Legal Business Name): JUNIPER VILLAGE AT STATE COLLEGE OPERATIONS II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 CLIFFSIDE DR
STATE COLLEGE PA
16801-7662
US

IV. Provider business mailing address

400 BROADACRES DR
BLOOMFIELD NJ
07003-3156
US

V. Phone/Fax

Practice location:
  • Phone: 814-235-2074
  • Fax: 814-235-2074
Mailing address:
  • Phone: 973-661-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number281302
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier395756
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS
# 2
Identifier395756
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER
# 3
Identifier232431939
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICARE SUPPLEMENTS
# 4
Identifier395756
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerADVANTRA
# 5
Identifier1461
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD

VIII. Authorized Official

Name: MS. LINDA C DONATO
Title or Position: VP OF MEMBER, JUNIPER PARTNERS LLC
Credential:
Phone: 973-661-8300