1316063324 NPI number — CHRIST THE KING MANOR, INC.

Table of content: (NPI 1316063324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316063324 NPI number — CHRIST THE KING MANOR, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRIST THE KING MANOR, INC.
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:
Provider Other Organization Name Type Code:
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:
1316063324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 448
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBOIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-371-3180
Provider Business Mailing Address Fax Number:
814-371-4101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 WEST LONG AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBOIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-371-3180
Provider Business Practice Location Address Fax Number:
814-371-4101
Provider Enumeration Date:
03/21/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FELTON-WERNER
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
814-371-3180

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  290102 , 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: 0689 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0007457620001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".