Provider Demographics
NPI:1669496287
Name:SUSQUEHANNA VILLAGE FACILITY OPERATIONS, LLC
Entity Type:Organization
Organization Name:SUSQUEHANNA VILLAGE FACILITY OPERATIONS, LLC
Other - Org Name:MANOR AT SUSQUEHANNA VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:USSERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-571-1550
Mailing Address - Street 1:800 CONCOURSE PKWY S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-6148
Mailing Address - Country:US
Mailing Address - Phone:407-571-1550
Mailing Address - Fax:407-571-1599
Practice Address - Street 1:990 MEDICAL RD
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17061-1235
Practice Address - Country:US
Practice Address - Phone:717-692-4751
Practice Address - Fax:717-692-4588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018126480001Medicaid
5917560001Medicare NSC
PA1018126480001Medicaid