Provider Demographics
NPI:1073645743
Name:DEVEREUX FOUNDATION - WHITLOCK
Entity Type:Organization
Organization Name:DEVEREUX FOUNDATION - WHITLOCK
Other - Org Name:WHITLOCK PCH
Other - Org Type:Other Name
Authorized Official - Title/Position:NATIONAL DIRECTOR, ACCTS RECEIVABLE
Authorized Official - Prefix:MS
Authorized Official - First Name:FRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-542-3084
Mailing Address - Street 1:133 LEOPARD RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19312-1809
Mailing Address - Country:US
Mailing Address - Phone:610-296-6800
Mailing Address - Fax:
Practice Address - Street 1:139 LEOPARD RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312-1809
Practice Address - Country:US
Practice Address - Phone:610-296-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA198110311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000019130006Medicaid
PA1000019130005Medicaid