Provider Demographics
NPI:1194728493
Name:CHURCH LANE SENIOR SERVICES, LLC
Entity type:Organization
Organization Name:CHURCH LANE SENIOR SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-527-4277
Mailing Address - Street 1:956 E RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3831
Mailing Address - Country:US
Mailing Address - Phone:610-525-8412
Mailing Address - Fax:610-525-1371
Practice Address - Street 1:43 CHURCH LN
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-2503
Practice Address - Country:US
Practice Address - Phone:610-356-3003
Practice Address - Fax:610-353-5859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA023102314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009799700001Medicaid
PA1009799700001Medicaid