=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699072553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 425 CEDARCREST ROAD OPERATING COMPANY, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2011
-----------------------------------------------------
Last Update Date | 09/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 CEDAR CREST DR
-----------------------------------------------------
City | QUAKERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18951-1620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-804-0736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 SENECA ST STE 100
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14204-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-361-6636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. DIRECTOR REVENUE CYCLE MGMT
-----------------------------------------------------
Name | KIMBERLY KENWORTHY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-361-6636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number | 136710
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------