Provider Demographics
NPI:1538133053
Name:ASBURY ATLANTIC, INC.
Entity Type:Organization
Organization Name:ASBURY ATLANTIC, INC.
Other - Org Name:BETHANY VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUNDUSKY
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:717-591-8027
Mailing Address - Street 1:5225 WILSON LN
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-6663
Mailing Address - Country:US
Mailing Address - Phone:717-591-8001
Mailing Address - Fax:717-766-0870
Practice Address - Street 1:5225 WILSON LN
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-6663
Practice Address - Country:US
Practice Address - Phone:717-591-8001
Practice Address - Fax:717-766-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA024402314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017505810003Medicaid
PA395386Medicare ID - Type Unspecified