1205290970 NPI number — TCM ADOLESCENT INITIATIVE AND FAMILY CARE CENTER

Table of content: (NPI 1205290970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205290970 NPI number — TCM ADOLESCENT INITIATIVE AND FAMILY CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TCM ADOLESCENT INITIATIVE AND FAMILY CARE CENTER
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:
1205290970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3401 CIVIC CENTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-4319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-590-2897
Provider Business Mailing Address Fax Number:
267-426-6313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 MARKET ST
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-3329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-590-2956
Provider Business Practice Location Address Fax Number:
215-590-7121
Provider Enumeration Date:
04/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BLEACHER
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
267-426-6179

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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