Basic Information
| Provider Information | |||||||||
| NPI: | 1659553048 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 100 EDELLA ROAD OPERATIONS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ABINGTON MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254463 | ||||||||
| FaxNumber: | 6109254351 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 EDELLA RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH ABINGTON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184111628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705861002 | ||||||||
| FaxNumber: | 5705869244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | DROPESKEY | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6109254231 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 053202 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1025687210001 | 05 | PA | MEDICAID |