Provider Demographics
NPI:1598765489
Name:MAHONING VALLEY CONVALESCENT HOME, INC.
Entity Type:Organization
Organization Name:MAHONING VALLEY CONVALESCENT HOME, INC.
Other - Org Name:MAHONING VALLEY NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:MICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-386-5522
Mailing Address - Street 1:397 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-9712
Mailing Address - Country:US
Mailing Address - Phone:570-386-5522
Mailing Address - Fax:570-386-3292
Practice Address - Street 1:397 HEMLOCK DR
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-9712
Practice Address - Country:US
Practice Address - Phone:570-386-5522
Practice Address - Fax:570-386-3292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA130202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007552770002Medicaid
PA0007552770002Medicaid