1417170549 NPI number — CLEM-MAR HOUSE, INC.

Table of content: (NPI 1417170549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417170549 NPI number — CLEM-MAR HOUSE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEM-MAR HOUSE, 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:
Provider Other Organization Name Type Code:
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:
1417170549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2028
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-7038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-674-1575
Provider Business Mailing Address Fax Number:
570-674-1588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2860 STATE ROUTE 309
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-674-1575
Provider Business Practice Location Address Fax Number:
570-674-1588
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REIMILLER
Authorized Official First Name:
MAUREEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PROJECT DIRECTOR
Authorized Official Telephone Number:
570-288-0403

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  407053 , 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: 0016199680003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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