Provider Demographics
NPI:1255323986
Name:BONETTI HEALTH CARE CENTER, INC
Entity Type:Organization
Organization Name:BONETTI HEALTH CARE CENTER, INC
Other - Org Name:AUTUMN GROVE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAURANO
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:724-735-4224
Mailing Address - Street 1:555 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16038-1623
Mailing Address - Country:US
Mailing Address - Phone:724-735-4224
Mailing Address - Fax:724-735-0103
Practice Address - Street 1:555 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:PA
Practice Address - Zip Code:16038-1623
Practice Address - Country:US
Practice Address - Phone:724-735-4224
Practice Address - Fax:724-735-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA022102314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
0569OtherBLUE CROSS
PA0007573330003Medicaid
395248Medicare PIN
0569OtherBLUE CROSS
PA395248Medicare Oscar/Certification