Provider Demographics
NPI:1225024003
Name:MID-VALLEY HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:MID-VALLEY HEALTH CARE CENTER LLC
Other - Org Name:MID-VALLEY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-969-2188
Mailing Address - Street 1:401 MOLTKE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2886
Mailing Address - Country:US
Mailing Address - Phone:570-969-2188
Mailing Address - Fax:570-969-2189
Practice Address - Street 1:81 STURGES RD
Practice Address - Street 2:
Practice Address - City:PECKVILLE
Practice Address - State:PA
Practice Address - Zip Code:18452-1302
Practice Address - Country:US
Practice Address - Phone:570-383-7320
Practice Address - Fax:570-383-5152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA027502314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102794713-0001Medicaid
PA395644Medicare Oscar/Certification