Healthcare Provider Details

I. General information

NPI: 1699720433
Provider Name (Legal Business Name): EDELLA STREET ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EDELLA RD
CLARKS SUMMIT PA
18411-1628
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 570-586-1002
  • Fax:
Mailing address:
  • Phone: 610-925-4436
  • Fax: 610-925-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number053202
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierIY0169
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHEALTHNET OF PA
# 2
Identifier39-5701
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBC OF NORTHEASTERN PA
# 3
Identifier82284
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA-HMO
# 4
Identifier21349
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER HEALTH PLANS
# 5
Identifier317116
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerUS FAMILY HEALTH PLAN
# 6
Identifier0010076320001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 7
Identifier080314
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerFIRST PRIORITY

VIII. Authorized Official

Name: JANE DROPESKEY
Title or Position: CORPORITE MANAGER
Credential:
Phone: 610-925-4231