1104949163 NPI number — DEVEREUX FOUNDATION COUNTRY CLUB

Table of content: (NPI 1104949163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104949163 NPI number — DEVEREUX FOUNDATION COUNTRY CLUB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEVEREUX FOUNDATION COUNTRY CLUB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WHITLOCK COUNTRY CLUB
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104949163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2012 RENAISSANCE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-2786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-542-3084
Provider Business Mailing Address Fax Number:
610-542-3191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
755 COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIXVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19460-2725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-296-6800
Provider Business Practice Location Address Fax Number:
610-251-2013
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
FRAN
Authorized Official Middle Name:
Authorized Official Title or Position:
NATIONAL ACCTS RECEIVABLE DIRECTOR
Authorized Official Telephone Number:
610-542-3084

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  504640 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1000019130308 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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