Provider Demographics
NPI:1104829571
Name:ST. MARY'S VILLA NURSING HOME, INC.
Entity Type:Organization
Organization Name:ST. MARY'S VILLA NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANARR
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:570-842-7621
Mailing Address - Street 1:516 SAINT MARYS VILLA RD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-9683
Mailing Address - Country:US
Mailing Address - Phone:570-842-7621
Mailing Address - Fax:570-842-2953
Practice Address - Street 1:516 SAINT MARYS VILLA RD
Practice Address - Street 2:
Practice Address - City:ELMHURST TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18444-9683
Practice Address - Country:US
Practice Address - Phone:570-842-7621
Practice Address - Fax:570-842-2953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA711502314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0754940Medicaid
PA395104Medicare Oscar/Certification
PA0611960001Medicare NSC