=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912629296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOYALSOCK OPERATING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2022
-----------------------------------------------------
Last Update Date | 11/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1445 SYCAMORE RD
-----------------------------------------------------
City | MONTOURSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17754-9519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-601-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 395 PEARSALL AVE STE K
-----------------------------------------------------
City | CEDARHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11516-1828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICAIL
-----------------------------------------------------
Name | GEDALIAH WIELGUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-601-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------