Provider Demographics
NPI:1033107073
Name:MILLVILLE LEASING PARTNERSHIP
Entity Type:Organization
Organization Name:MILLVILLE LEASING PARTNERSHIP
Other - Org Name:LAKESIDE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT LEHIGH NURSING CORP
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAYMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:610-264-8000
Mailing Address - Street 1:357 OLD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612
Mailing Address - Country:US
Mailing Address - Phone:570-639-1885
Mailing Address - Fax:570-639-5163
Practice Address - Street 1:357 OLD LAKE RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612
Practice Address - Country:US
Practice Address - Phone:570-639-1885
Practice Address - Fax:570-639-5163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA290902314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007557700003Medicaid
PA1007557700003Medicaid
PA395730Medicare Oscar/Certification