Provider Demographics
NPI:1083707178
Name:ELM TERRACE GARDENS
Entity Type:Organization
Organization Name:ELM TERRACE GARDENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:MCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:215-361-5664
Mailing Address - Street 1:660 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2361
Mailing Address - Country:US
Mailing Address - Phone:215-361-5664
Mailing Address - Fax:215-361-5670
Practice Address - Street 1:660 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2361
Practice Address - Country:US
Practice Address - Phone:215-361-5664
Practice Address - Fax:215-361-5670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAA45280310400000X
PA310802314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA54338OtherAETNA PROVIDER #
PA0005832000OtherBLUE CROSS/KEYSTONE PROV#
PA10081441140003Medicaid
PA10081441140003Medicaid