NCF Initial Provider Application

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The Pavilion at St. Luke Village
1000 Stacie Dr
Hazleton, 18201-5690
Application ID: 4613018

Step 1: Application

Step 3: Agreement

Step 4: Payment

Status: Final Review

The "Submit Comment" button is available at the bottom of this provider application review page. Clicking "Submit Comment" will display the comment form. You can enter your comment on the form and choose whether to identify yourself. Please note that information entered on the comment form will not be viewable publicly.

** Note: You may view any files you Attach upon Saving. **

Facility Name

Street Address

Address 2

City County

Zip Code Phone #

Applicant/Owner Name

Anticipated Start Date of Operation (MM/DD/YYYY)

Type of Application

New

Change of Ownership

Note that upon entry of a valid Previous License Number, Previous Name and License Expiration date will be automatically set upon saving of this Provider Application.

	If Change of Ownership, enter Previous License Number:	Previous Name:
		License Expiration:

Type of Ownership

Individual

Partnership

Corporation

City/County Government

Hospital Based

State Government

Type of Operation

Profit

Non-Profit

Have you increased your bed capacity by 10% or more, or by 10 beds, whichever is greater, within the last 2 years?

Yes

If Yes, give year of change Current Beds Prior Beds

Current Licensed Capacity: Requested Capacity:

Current License Number:

Administrator

Administrator Name License Number

Applicant Name and Address

Applicant Name

Applicant Address

City State

Zip Code Phone #

Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVIII, XIX, or XX?

Yes

Has there been a change in ownership or control within the last year?

Yes

If Yes, give date

Do you anticipate any change of ownership or control within the year?

Yes

If Yes, when?

Do you anticipate filing for bankruptcy within the year?

Yes

If Yes, when?

Is the county operated or sponsered?

Yes

If yes, enter address of Board of Commissioners and name of commissioners

Board Name and Address

Commissioner Name

Is the facility and/or building -

owned

leased

If leased, list the name and address of lessor.

Lessor Name

Lessor Address

City State Zip Code

Is the facility managed by an organization other than licensee?

Yes

If yes, list the name and address of the organization.

Management Name

Management Address

City State Zip Code

List name and address of all persons having ownership of 5% or more (Type in or attach a document.)

Grove of Hazel ParentCo LLC (100%) 1040 Crown Pointe Pkwy., Ste. 600, Atlanta, GA 30338

If appropriate, list the name and address of trustees or boardmembers. (Type in or attach a document.)

Not Applicable

Are there any individuals or organizations having a direct or indirect ownership or control interest of 5 percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any of the programs established by Titles XVIII, XIX, or XX?

Yes

Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's organization's, or agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only)

Yes

Is the facility's ownership involved with a pyramid or parent corporate structure? If applicable, list name and address of parent corporation or pyramid corporate structures. Explain as necessary. (Type in or attach a document.)

Yes

Does owner(s) or corporate members have financial interest in other health care facilities?

Yes

If yes, list name and address of all other health care facilities in which the owner or corporate members have financial interest. (Type in or attach a document.)