1205967759 NPI number — DAYSTAR CENTER FOR SPIRITUAL RECOVERY

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 1205967759 NPI number — DAYSTAR CENTER FOR SPIRITUAL RECOVERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAYSTAR CENTER FOR SPIRITUAL RECOVERY
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:
1205967759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60574
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-230-9898
Provider Business Mailing Address Fax Number:
717-238-1793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 N. 18TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-230-9898
Provider Business Practice Location Address Fax Number:
717-238-1793
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILCOX
Authorized Official First Name:
FERN
Authorized Official Middle Name:
ROBERTA
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
717-230-9898

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  227077 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X , 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: 100035 . This is a "CCBH IDENTIFIER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0018539150001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 227077 . This is a "DEPT OF HEALTH FACILITY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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