1629108741 NPI number — ERIE INDEPENDENCE HOUSE, INC.

Table of content: (NPI 1629108741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629108741 NPI number — ERIE INDEPENDENCE HOUSE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERIE INDEPENDENCE 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:
1629108741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1611 PEACH ST
Provider Second Line Business Mailing Address:
SUITE 145
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16501-2109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-461-9188
Provider Business Mailing Address Fax Number:
814-461-0232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3108 ZUCK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16506-3161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-833-9955
Provider Business Practice Location Address Fax Number:
814-835-1772
Provider Enumeration Date:
03/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCHLAUDECKER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
814-461-9188

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  805640 , 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: 1007694800001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".