Provider Demographics
NPI:1184396137
Name:RODRIGUES, STEPHEN (PRESIDENT/CEO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:RODRIGUES
Suffix:
Gender:M
Credentials:PRESIDENT/CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:NANTY GLO
Mailing Address - State:PA
Mailing Address - Zip Code:15943-1209
Mailing Address - Country:US
Mailing Address - Phone:814-749-8799
Mailing Address - Fax:814-749-8799
Practice Address - Street 1:1075 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NANTY GLO
Practice Address - State:PA
Practice Address - Zip Code:15943-1209
Practice Address - Country:US
Practice Address - Phone:814-749-8799
Practice Address - Fax:814-749-8799
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
PA327360310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA327360OtherLICENSE
PA327360OtherDEPARTMENT OF HEALTH PA