Provider Demographics
NPI:1649268921
Name:MARY ELLEN CONVALESCENT HOME INC
Entity type:Organization
Organization Name:MARY ELLEN CONVALESCENT HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KECK
Authorized Official - Suffix:
Authorized Official - Credentials:ADM, RN
Authorized Official - Phone:610-838-7901
Mailing Address - Street 1:1896 LEITHSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HELLERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18055-2505
Mailing Address - Country:US
Mailing Address - Phone:610-838-7901
Mailing Address - Fax:610-838-8347
Practice Address - Street 1:1896 LEITHSVILLE RD
Practice Address - Street 2:
Practice Address - City:HELLERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18055-2505
Practice Address - Country:US
Practice Address - Phone:610-838-7901
Practice Address - Fax:610-838-8347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396024Medicare Oscar/Certification