Provider Demographics
NPI:1891746178
Name:GGNSC ERIE WESTERN RESERVE LP
Entity Type:Organization
Organization Name:GGNSC ERIE WESTERN RESERVE LP
Other - Org Name:GOLDEN LIVINGCENTER - WESTERN RESERVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC. OF THE GP
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RASMUSSEN-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-201-4835
Mailing Address - Street 1:1521 W 54TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2620
Mailing Address - Country:US
Mailing Address - Phone:814-864-0671
Mailing Address - Fax:814-866-5681
Practice Address - Street 1:1521 W 54TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2620
Practice Address - Country:US
Practice Address - Phone:814-864-0671
Practice Address - Fax:814-866-5681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA490802314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0656OtherHIGHMARK WESTERN PA
PA1007774460023OtherION HEALTH
PA1015518640001Medicaid
PA318038OtherUPMC
PA101551864Medicaid
PA1505090OtherGATEWAY HEALTH PLAN
PA000000079448OtherTHREE RIVERS HEALTH PLAN
NY00745097Medicaid
PA84012OtherHEALTH AMERICA
PA1505090OtherGATEWAY HEALTH PLAN
PA395262Medicare Oscar/Certification