Provider Demographics
NPI:1932185634
Name:ST MARYS MANOR
Entity Type:Organization
Organization Name:ST MARYS MANOR
Other - Org Name:ST MARYS MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CZEKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-368-0900
Mailing Address - Street 1:701 LANSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2958
Mailing Address - Country:US
Mailing Address - Phone:215-368-0900
Mailing Address - Fax:215-368-5254
Practice Address - Street 1:701 LANSDALE AVE
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2958
Practice Address - Country:US
Practice Address - Phone:215-368-0900
Practice Address - Fax:215-368-5254
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC HEALTH CARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-15
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA144490310400000X
PA451402314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA005684OtherIBC KEYSTONE
PA0007491620001Medicaid
PA0007491620001Medicaid