Healthcare Provider Details

I. General information

NPI: 1871577155
Provider Name (Legal Business Name): ST MONICA MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 S 4TH ST
PHILADELPHIA PA
19148-4712
US

IV. Provider business mailing address

2509 S 4TH ST
PHILADELPHIA PA
19148-4712
US

V. Phone/Fax

Practice location:
  • Phone: 215-271-1080
  • Fax: 215-271-6290
Mailing address:
  • Phone: 215-271-1080
  • Fax: 215-271-6290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number232602
License Number StatePA

VIII. Authorized Official

Name: MR. MICHAEL CZEKNER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 215-368-0900