=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710348305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAYBROOK-C WHITECLIFF OPCO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2016
-----------------------------------------------------
Last Update Date | 04/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 FREDONIA ROAD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16125-7911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-588-8090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 FREDONIA ROAD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16125-7911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-588-8090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. RONALD S. JORDAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-588-8090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------