Provider Demographics
NPI:1790783017
Name:HOME FOR THE AGED OF THE LITTLE SISTERS OF THE POOR
Entity Type:Organization
Organization Name:HOME FOR THE AGED OF THE LITTLE SISTERS OF THE POOR
Other - Org Name:HOLY FAMILY RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:MISTRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:LSP
Authorized Official - Phone:570-343-4065
Mailing Address - Street 1:2500 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-1515
Mailing Address - Country:US
Mailing Address - Phone:570-343-4065
Mailing Address - Fax:570-343-8913
Practice Address - Street 1:2500 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-1515
Practice Address - Country:US
Practice Address - Phone:570-343-4065
Practice Address - Fax:570-343-8913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA860302314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007509960001Medicaid
PA395625Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.