Provider Demographics
NPI:1699306449
Name:MILLCREEK MANOR
Entity type:Organization
Organization Name:MILLCREEK MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMAURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-868-2496
Mailing Address - Street 1:5535 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2603
Mailing Address - Country:US
Mailing Address - Phone:814-453-5072
Mailing Address - Fax:
Practice Address - Street 1:3910 SCHAPER AVE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-3346
Practice Address - Country:US
Practice Address - Phone:814-453-5072
Practice Address - Fax:814-452-1578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012079290005Medicaid