1194840736 NPI number — GAUDENZIA INC

Table of content: (NPI 1194840736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194840736 NPI number — GAUDENZIA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GAUDENZIA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GAUDENZIA CONCEPT 90
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194840736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORRISTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19401-4716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-239-9600
Provider Business Mailing Address Fax Number:
610-275-7025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 EAST AZALEA DRIVE
Provider Second Line Business Practice Location Address:
ANDERSON HALL
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-232-3232
Provider Business Practice Location Address Fax Number:
717-236-6833
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR CONTRACTING MANAGER
Authorized Official Telephone Number:
484-338-3731

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  221159 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1002285890037 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1002285890038 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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