Provider Demographics
NPI:1760099311
Name:EMBASSY PARK AVENUE, LLC
Entity Type:Organization
Organization Name:EMBASSY PARK AVENUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:REPCHICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-378-2050
Mailing Address - Street 1:25201 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14714 PARK AVENUE EXT
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-9400
Practice Address - Country:US
Practice Address - Phone:814-337-4228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility