Provider Demographics
NPI:1134135577
Name:PENNKNOLL VILLAGE FACILITY OPERATIONS, LLC
Entity Type:Organization
Organization Name:PENNKNOLL VILLAGE FACILITY OPERATIONS, LLC
Other - Org Name:PENNKNOLL VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:USSERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-571-1550
Mailing Address - Street 1:208 PENNKNOLL RD
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-6940
Mailing Address - Country:US
Mailing Address - Phone:814-623-3200
Mailing Address - Fax:814-623-3202
Practice Address - Street 1:208 PENNKNOLL RD
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-6940
Practice Address - Country:US
Practice Address - Phone:814-623-3200
Practice Address - Fax:814-623-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018134940001Medicaid
39-5422Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER