Provider Demographics
NPI:1497998876
Name:SENIORLIFE WASHINGTON, INC.
Entity Type:Organization
Organization Name:SENIORLIFE WASHINGTON, INC.
Other - Org Name:SENIORLIFE WASHINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:HENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-963-9150
Mailing Address - Street 1:209 SIGMA DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2826
Mailing Address - Country:US
Mailing Address - Phone:412-996-3915
Mailing Address - Fax:412-963-6676
Practice Address - Street 1:2114 NORTH FRANKLIN DRIVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301
Practice Address - Country:US
Practice Address - Phone:724-222-5433
Practice Address - Fax:814-248-7902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251T00000X
PA19943601253Z00000X
PA19953601253Z00000X
PA084480261QA0600X
PA084490261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102324931-0002Medicaid
PA102324931-0001Medicaid
PAH2992OtherMEDICARE PACE PROGRAM AGREEMENT