Provider Demographics
NPI:1760483440
Name:DAVIS NURSING HOME, INC.
Entity Type:Organization
Organization Name:DAVIS NURSING HOME, INC.
Other - Org Name:DAVIS MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:570-474-6377
Mailing Address - Street 1:185 S MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1921
Mailing Address - Country:US
Mailing Address - Phone:570-474-6377
Mailing Address - Fax:570-474-6712
Practice Address - Street 1:185 S MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707-1921
Practice Address - Country:US
Practice Address - Phone:570-474-6377
Practice Address - Fax:570-474-6712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA040802314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007448900002Medicaid
395542Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO