Provider Demographics
NPI:1275547036
Name:MANOR AT ST. LUKE VILLAGE FACILITY OPERATIONS, LLC
Entity Type:Organization
Organization Name:MANOR AT ST. LUKE VILLAGE FACILITY OPERATIONS, LLC
Other - Org Name:THE MANOR AT ST. LUKE VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
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 1:1711 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-5691
Mailing Address - Country:US
Mailing Address - Phone:570-453-5100
Mailing Address - Fax:570-453-5138
Practice Address - Street 1:1711 E BROAD ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-5691
Practice Address - Country:US
Practice Address - Phone:570-453-5100
Practice Address - Fax:570-453-5138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
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
PA1018125210001Medicaid
5957660001Medicare NSC
39-5636Medicare PIN