Provider Demographics
NPI:1043216351
Name:CENTRE CREST
Entity Type:Organization
Organization Name:CENTRE CREST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-355-6777
Mailing Address - Street 1:502 E HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823
Mailing Address - Country:US
Mailing Address - Phone:814-355-6777
Mailing Address - Fax:814-355-6999
Practice Address - Street 1:502 E HOWARD ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTE
Practice Address - State:PA
Practice Address - Zip Code:16823
Practice Address - Country:US
Practice Address - Phone:814-355-6777
Practice Address - Fax:814-355-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA031702314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA031702OtherDOH STATE LICENSE NUMBER
PA1007296630007Medicaid
395779Medicare ID - Type Unspecified