Provider Demographics
NPI:1043207152
Name:EVANGELICAL MANOR
Entity Type:Organization
Organization Name:EVANGELICAL MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LACHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:215-624-5800
Mailing Address - Street 1:928 JAYMOR RD
Mailing Address - Street 2:SUITE B-150
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3826
Mailing Address - Country:US
Mailing Address - Phone:215-354-9586
Mailing Address - Fax:215-354-1435
Practice Address - Street 1:8401 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2034
Practice Address - Country:US
Practice Address - Phone:215-624-5800
Practice Address - Fax:215-335-1477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA311202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007449700001Medicaid
PA2123484OtherAETNA PROVIDER ID
PA0005920000OtherIBC PROVIDER ID
PA395413Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBR