1184882805 NPI number — MOUNT TREXLER MANOR

Table of content: DR. YOOKYUNG ANDREA PARK O.D. (NPI 1295188456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184882805 NPI number — MOUNT TREXLER MANOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNT TREXLER MANOR
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:
1184882805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5201 SAINT JOSEPHS ROAD
Provider Second Line Business Mailing Address:
PO BOX 1001
Provider Business Mailing Address City Name:
LIMEPORT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18060-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-965-9021
Provider Business Mailing Address Fax Number:
610-928-0174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5201 SAINT JOSEPHS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIMEPORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18060-0010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-965-9021
Provider Business Practice Location Address Fax Number:
610-928-0174
Provider Enumeration Date:
05/29/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MUTH
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PROJECT MANAGEMENT
Authorized Official Telephone Number:
610-965-9021

Provider Taxonomy Codes

  • Taxonomy code: 3104A0625X , with the licence number:  216630 , 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)