1295890002 NPI number — GLADE RUN LUTHERAN SERVICES

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 1295890002 NPI number — GLADE RUN LUTHERAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLADE RUN LUTHERAN SERVICES
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:
1295890002
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:
PO BOX 70
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZELIENOPLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16063-0070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-452-4453
Provider Business Mailing Address Fax Number:
724-452-6576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BEAVER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZELIENOPLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16063-0070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-452-4453
Provider Business Practice Location Address Fax Number:
724-452-6576
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKWOOD
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
T
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
724-452-4453

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  403080 , 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: 100754254-0003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com