Healthcare Provider Details

I. General information

NPI: 1578568135
Provider Name (Legal Business Name): BOARD OF DIRECTORS OF THE ROUSE ESTATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 ROUSE AVE
YOUNGSVILLE PA
16371-1605
US

IV. Provider business mailing address

701 ROUSE AVE
YOUNGSVILLE PA
16371-1605
US

V. Phone/Fax

Practice location:
  • Phone: 814-563-7565
  • Fax: 814-563-9049
Mailing address:
  • Phone: 814-563-7565
  • Fax: 814-563-9049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number181702
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number181702
License Number StatePA

VIII. Authorized Official

Name: MR. JASEN J. DILEY
Title or Position: CEO
Credential:
Phone: 814-563-6403