Provider Demographics
NPI:1578568135
Name:BOARD OF DIRECTORS OF THE ROUSE ESTATE
Entity Type:Organization
Organization Name:BOARD OF DIRECTORS OF THE ROUSE ESTATE
Other - Org Name:THE ROUSE ESTATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-563-6403
Mailing Address - Street 1:701 ROUSE AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16371-1605
Mailing Address - Country:US
Mailing Address - Phone:814-563-7565
Mailing Address - Fax:814-563-9049
Practice Address - Street 1:701 ROUSE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16371-1605
Practice Address - Country:US
Practice Address - Phone:814-563-7565
Practice Address - Fax:814-563-9049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA181702261QP2000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0360560001OtherNSC#
PA1001382300004Medicaid
PA1001382300004Medicaid