MEDICARE: WEDGEWOOD NURSING HOME, L.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BN1400X	Nursing Facility Supplies (DME)	115374	TX
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	115374	TX
3	314000000X	Skilled Nursing Facility	115374	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174575625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEDGEWOOD NURSING HOME, L.P.

Provider Business Mailing Address
First Line	:	200 DRYDEN RD E
Second Line	:
City	:	DRESHER
State	:	PA
Zip	:	19025-1048
Country	:	US
Telephone Number	:	215-441-7700
Fax Number	:	215-441-4255

Provider Business Practice Location Address
First Line	:	6621 DAN DANCIGER RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-4905
Country	:	US
Telephone Number	:	817-292-6330
Fax Number	:	817-346-7980

Authorized Official
Title or Position	:	PRESIDENT OF GENERAL PARTNER
Name	:	MR. PETER J LICARI
Credential	:
Telephone Number	:	215-441-7700

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	10/30/2007

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