Healthcare Provider Details

I. General information

NPI: 1043207152
Provider Name (Legal Business Name): EVANGELICAL MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 ROOSEVELT BLVD
PHILADELPHIA PA
19152-2034
US

IV. Provider business mailing address

928 JAYMOR RD SUITE B-150
SOUTHAMPTON PA
18966-3826
US

V. Phone/Fax

Practice location:
  • Phone: 215-624-5800
  • Fax: 215-335-1477
Mailing address:
  • Phone: 215-354-9586
  • Fax: 215-354-1435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number311202
License Number StatePA

VIII. Authorized Official

Name: MS. SUZANNE LACHMAN
Title or Position: EXECUTIVE DIRECTOR
Credential: NHA
Phone: 215-624-5800