Provider Demographics
NPI:1679570196
Name:RIDDLE VILLAGE
Entity Type:Organization
Organization Name:RIDDLE VILLAGE
Other - Org Name:MONTICELLO HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO/VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGUSZEUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-891-3783
Mailing Address - Street 1:1048 W BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5149
Mailing Address - Country:US
Mailing Address - Phone:610-891-3806
Mailing Address - Fax:610-891-3829
Practice Address - Street 1:1048 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5149
Practice Address - Country:US
Practice Address - Phone:610-891-3806
Practice Address - Fax:610-891-3829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA017302314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1451OtherINDEPENDENCE BLUE CROSS
PA576790OtherAETNA/US HEALTHCARE
PA391335OtherHIGHMARK BLUE CROSS
PA395974Medicare ID - Type UnspecifiedMEDICARE