1174640833 NPI number — DIVINE PROVIDENCE VILLAGE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174640833 NPI number — DIVINE PROVIDENCE VILLAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE PROVIDENCE VILLAGE
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:
1174640833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
686 OLD MARPLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19064-1239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-328-7730
Provider Business Mailing Address Fax Number:
610-544-1710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
394 LAROSE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COATESVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19320-1628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-543-5410
Provider Business Practice Location Address Fax Number:
610-543-5397
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ENGEL
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
HIPAA OFFICER
Authorized Official Telephone Number:
610-525-8800

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , 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: 1000031590084 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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