MEDICARE: PARK VILLAGE AL NP LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1366170854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK VILLAGE AL NP LLC

Provider Business Mailing Address
First Line	:	1019 OLDTOWN VALLEY RD SE
Second Line	:
City	:	NEW PHILADELPHIA
State	:	OH
Zip	:	44663-8125
Country	:	US
Telephone Number	:	330-447-3490
Fax Number	:	330-440-6000

Provider Business Practice Location Address
First Line	:	1019 OLDTOWN VALLEY RD SE
Second Line	:
City	:	NEW PHILADELPHIA
State	:	OH
Zip	:	44663-8125
Country	:	US
Telephone Number	:	330-447-3490
Fax Number	:	330-440-6000

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. JEFFREY H TUCKER
Credential	:
Telephone Number	:	330-447-3490

Provider Enumeration Date	:	08/11/2022
Last Update Date	:	08/11/2022

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