Provider Demographics
NPI:1164878070
Name:CHRIST THE KING MANOR
Entity Type:Organization
Organization Name:CHRIST THE KING MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDRULONIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-371-3180
Mailing Address - Street 1:1100 W LONG AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-3986
Mailing Address - Country:US
Mailing Address - Phone:814-371-3180
Mailing Address - Fax:814-371-4101
Practice Address - Street 1:1100 W LONG AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-3986
Practice Address - Country:US
Practice Address - Phone:814-371-3180
Practice Address - Fax:814-371-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA18633601253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1316063324Medicaid