Provider Demographics
NPI:1336149129
Name:WILLIAMSPORT HOME
Entity Type:Organization
Organization Name:WILLIAMSPORT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:POTE
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:570-323-8781
Mailing Address - Street 1:1900 RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1799
Mailing Address - Country:US
Mailing Address - Phone:570-323-8781
Mailing Address - Fax:570-323-4858
Practice Address - Street 1:1900 RAVINE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1799
Practice Address - Country:US
Practice Address - Phone:570-323-8781
Practice Address - Fax:570-323-4858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA491902314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
800632OtherFIRST PRIORITY
PA0007492980001Medicaid
800632OtherFIRST PRIORITY