Provider Demographics
NPI:1295718039
Name:PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES
Entity type:Organization
Organization Name:PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-772-2518
Mailing Address - Street 1:10058 S MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH MOUNTAIN
Mailing Address - State:PA
Mailing Address - Zip Code:17261-0900
Mailing Address - Country:US
Mailing Address - Phone:717-749-4000
Mailing Address - Fax:717-749-4071
Practice Address - Street 1:10058 S MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SOUTH MOUNTAIN
Practice Address - State:PA
Practice Address - Zip Code:17261-0900
Practice Address - Country:US
Practice Address - Phone:717-749-4000
Practice Address - Fax:717-749-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-25
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100308518Medicaid
PAC30956Medicare PIN
PA395583Medicare Oscar/Certification
PA660418Medicare ID - Type UnspecifiedCLINICAL SERVICES