Healthcare Provider Details

I. General information

NPI: 1477665198
Provider Name (Legal Business Name): WYNCOTE CHURCH HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 FERNBROOK AVENUE
WYNCOTE PA
19095-1509
US

IV. Provider business mailing address

208 FERNBROOK AVENUE
WYNCOTE PA
19095-1532
US

V. Phone/Fax

Practice location:
  • Phone: 215-883-2620
  • Fax: 215-885-9245
Mailing address:
  • Phone: 215-883-2620
  • Fax: 215-690-3340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number232102
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0007565230002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. SCOTT R STEVENSON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 610-794-5131