# 69 COTTAGE ROAD OPCO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Locust Grove Retirement Village
- **Organization subpart:** No

## Provider details

- **NPI number:** 1922816966
- **Authorized official:** TIFFANY HOBACK (MANAGER)
- **Authorized official phone:** (770) 698-9040

## Contact information

- **Practice address:** 69 COTTAGE RD, MIFFLIN, PA 17058-7030
- **Practice address phone:** (717) 436-8921
- **Practice address fax:** (717) 436-9165
- **Mailing address:** 69 COTTAGE RD, MIFFLIN, PA 17058-7030
- **Mailing address phone:** (717) 436-8921
- **Mailing address fax:** (717) 436-9165

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 12/23/2024
- **Last updated:** 03/10/2025