Provider Demographics
NPI:1154372522
Name:GGNSC WILKES-BARRE II LP
Entity type:Organization
Organization Name:GGNSC WILKES-BARRE II LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SEC. OF THE GP
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RASMUSSEN-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-201-4835
Mailing Address - Street 1:50 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-3503
Mailing Address - Country:US
Mailing Address - Phone:570-825-3488
Mailing Address - Fax:570-825-9423
Practice Address - Street 1:50 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3503
Practice Address - Country:US
Practice Address - Phone:570-825-3488
Practice Address - Fax:570-825-9423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA971402314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101558613Medicaid
PA000000130630OtherTHREE RIVERS HEALTH PLAN
PA1015586130001Medicaid
PA30946OtherGEISINGER HEALTH PLAN
PA1526893OtherGATEWAY HEALTH PLAN
PA395456Medicare Oscar/Certification
PA1526893OtherGATEWAY HEALTH PLAN