Healthcare Provider Details

I. General information

NPI: 1780436410
Provider Name (Legal Business Name): EMBASSY OF TUNKHANNOCK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 VIRGINIA DR
TUNKHANNOCK PA
18657-1701
US

IV. Provider business mailing address

25201 CHAGRIN BLVD STE 190
BEACHWOOD OH
44122-5633
US

V. Phone/Fax

Practice location:
  • Phone: 216-378-2050
  • 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: NICHOLAS CICCONE
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 216-378-2050