NPIMap

Organization Active NPI

Devereux Foundation Country Club

  • Intellectual Disabilities Intermediate Care Facility
  • Phoenixville, PA
National Provider Identifier
1104949163
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
504640 Issued in PA
Legal business name
DEVEREUX FOUNDATION COUNTRY CLUB
Practice address
755 Country Club Rd
Phoenixville, PA 19460-2725
Phone
(610) 296-6800
Fax
(610) 251-2013
NPI assigned
Apr 6, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Fran Wagner
Title
National Accts Receivable Director
Phone
(610) 542-3084

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 504640 PA Primary

Addresses

Primary practice location

755 Country Club Rd
Phoenixville, PA 19460-2725

Mailing address

2012 Renaissance Blvd
King of Prussia, PA 19406-2786
Phone (610) 542-3084

Other identifiers 1

IdentifierTypeStateIssuer
1000019130308MedicaidPA

Other names 1

  • Whitlock Country Club Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104949163. Details of each certification follow.

  • CCN 39G240 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 39G240

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
THE DEVEREUX FOUNDATION - COUNTRY CLUB
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Oct 15, 1990
Last certification
Apr 11, 2025
Beds
5
Ownership / control type
Private (non-profit)
Facility address
755 Country Club Road
Phoenixville, PA 19460

National Provider Directory

National Provider Directory
Tax ID family
Comm SVCS of Devereux332 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1104949163",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2012 RENAISSANCE BLVD",
            "city": "KING OF PRUSSIA",
            "state": "PA",
            "postal_code": "194062786",
            "telephone_number": "610-542-3084",
            "fax_number": "610-542-3191"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "755 COUNTRY CLUB RD",
            "city": "PHOENIXVILLE",
            "state": "PA",
            "postal_code": "194602725",
            "telephone_number": "610-296-6800",
            "fax_number": "610-251-2013"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEVEREUX FOUNDATION COUNTRY CLUB",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-06",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WAGNER",
        "authorized_official_first_name": "FRAN",
        "authorized_official_title_or_position": "NATIONAL ACCTS RECEIVABLE DIRECTOR",
        "authorized_official_telephone_number": "610-542-3084"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "PA",
            "license": "504640",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1000019130308",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Whitlock Country Club",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Phoenixville, PA

Sources for this page

Verify at the official NPI Registry.