Provider Demographics
NPI:1174586002
Name:UNIVERSITY PARK NURSING, LP
Entity type:Organization
Organization Name:UNIVERSITY PARK NURSING, LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:LICARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-441-7700
Mailing Address - Street 1:450 WAUPELANI DRIVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-4516
Mailing Address - Country:US
Mailing Address - Phone:814-237-0630
Mailing Address - Fax:814-237-1803
Practice Address - Street 1:450 WAUPELANI DRIVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-4516
Practice Address - Country:US
Practice Address - Phone:814-237-0630
Practice Address - Fax:814-237-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA940502314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101188085Medicaid
PA4901777625Medicaid
PA395868Medicare Oscar/Certification