Provider Demographics
NPI:1669463949
Name:VALLEY CREST NURSING HOME (LUZERNE COUNTY)
Entity Type:Organization
Organization Name:VALLEY CREST NURSING HOME (LUZERNE COUNTY)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:570-826-1011
Mailing Address - Street 1:1551 E END BLVD
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-0576
Mailing Address - Country:US
Mailing Address - Phone:570-826-1011
Mailing Address - Fax:570-825-1211
Practice Address - Street 1:1551 E END BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0576
Practice Address - Country:US
Practice Address - Phone:570-826-1011
Practice Address - Fax:570-825-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA220102314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0752275Medicaid
PA0752275Medicaid