Provider Demographics
NPI:1487814430
Name:CLOVERDALE PERSONAL CARE HOME
Entity Type:Organization
Organization Name:CLOVERDALE PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:ASSAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-583-0620
Mailing Address - Street 1:206 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MASONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15461-1646
Mailing Address - Country:US
Mailing Address - Phone:724-583-0620
Mailing Address - Fax:724-583-0620
Practice Address - Street 1:206 WESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:MASONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15461-1646
Practice Address - Country:US
Practice Address - Phone:724-583-0620
Practice Address - Fax:724-583-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA438900311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home