Provider Demographics
NPI:1396946489
Name:GUARDIAN ELDER CARE AT BROCKWAY LLC
Entity type:Organization
Organization Name:GUARDIAN ELDER CARE AT BROCKWAY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ARMANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTUNATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-265-1164
Mailing Address - Street 1:8796 ROUTE 219
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15824-6010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:PA
Practice Address - Zip Code:15824-1038
Practice Address - Country:US
Practice Address - Phone:814-265-8265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101956791-0001Medicaid
PA395877Medicare Oscar/Certification
PA1396946489Medicare NSC