Basic Information
| Provider Information | |||||||||
| NPI: | 1841284098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESBYTERIAN HOMES INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SYCAMORE MANOR HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 TRINITY DR E | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DILLSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170198522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175028840 | ||||||||
| FaxNumber: | 7175028843 | ||||||||
| Practice Location | |||||||||
| Address1: | 1445 SYCAMORE RD | ||||||||
| Address2: | |||||||||
| City: | MONTOURSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177549519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703262037 | ||||||||
| FaxNumber: | 7177376763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 07/01/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASNER | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7175028922 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHI | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 194402 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1007494880015 | 05 | PA | MEDICAID |