Provider Demographics
NPI:1316063324
Name:CHRIST THE KING MANOR, INC.
Entity type:Organization
Organization Name:CHRIST THE KING MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:FELTON-WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:814-371-3180
Mailing Address - Street 1:P.O. BOX 448
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801
Mailing Address - Country:US
Mailing Address - Phone:814-371-3180
Mailing Address - Fax:814-371-4101
Practice Address - Street 1:1100 WEST LONG AVENUE
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:PA
Practice Address - Zip Code:15801
Practice Address - Country:US
Practice Address - Phone:814-371-3180
Practice Address - Fax:814-371-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA290102314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0689OtherBLUE CROSS BLUE SHIELD
PA0007457620001Medicaid
PA0689OtherBLUE CROSS BLUE SHIELD