Provider Demographics
NPI:1003166802
Name:SENIOR LIFE GREENSBURG, INC
Entity Type:Organization
Organization Name:SENIOR LIFE GREENSBURG, INC
Other - Org Name:SENIOR LIFE GREENSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR. OF REIMBURSEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:HENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-963-9150
Mailing Address - Street 1:209 SIGMA DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2826
Mailing Address - Country:US
Mailing Address - Phone:412-963-9150
Mailing Address - Fax:412-963-6676
Practice Address - Street 1:123 TRIANGLE DRIVE
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-3510
Practice Address - Country:US
Practice Address - Phone:724-838-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251T00000X
PA075064261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102768642-0001Medicaid
PAH2937OtherMEDICARE PACE PROVIDER AGREEMENT