Healthcare Provider Details

I. General information

NPI: 1649267477
Provider Name (Legal Business Name): MEDA NIPPLE CONVALESCENT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 109
THOMPSONTOWN PA
17094-9722
US

IV. Provider business mailing address

RR 1 BOX 109
THOMPSONTOWN PA
17094-9722
US

V. Phone/Fax

Practice location:
  • Phone: 717-463-2632
  • Fax: 775-255-4723
Mailing address:
  • Phone: 717-463-2632
  • Fax: 775-255-4723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number131802
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0007547340001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MRS. KATHLEEN TEKLA NIPPLE
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 717-463-2632