Provider Demographics
NPI:1336289446
Name:LIFE BEAVER COUNTY
Entity Type:Organization
Organization Name:LIFE BEAVER COUNTY
Other - Org Name:LIFE BEAVER
Other - Org Type:Other Name
Authorized Official - Title/Position:C. F. O.
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:Q
Authorized Official - Last Name:DIGIROLAMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-776-1100
Mailing Address - Street 1:1323 FREEDOM RD
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-5001
Mailing Address - Country:US
Mailing Address - Phone:724-776-1100
Mailing Address - Fax:724-776-0811
Practice Address - Street 1:131 PLEASANT DR
Practice Address - Street 2:CENTERPLACE SUITE 1
Practice Address - City:ALIQUIPPA
Practice Address - State:PA
Practice Address - Zip Code:15001-1384
Practice Address - Country:US
Practice Address - Phone:724-378-5400
Practice Address - Fax:724-302-2093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA043820251T00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019765400001Medicaid