Provider Demographics
NPI:1548268840
Name:DUNWOODY VILLAGE
Entity type:Organization
Organization Name:DUNWOODY VILLAGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-359-4426
Mailing Address - Street 1:3500 W CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-4101
Mailing Address - Country:US
Mailing Address - Phone:610-359-4400
Mailing Address - Fax:610-359-4498
Practice Address - Street 1:3500 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-4101
Practice Address - Country:US
Practice Address - Phone:610-359-4400
Practice Address - Fax:610-359-4498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA041602314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39-5329Medicare ID - Type Unspecified