1366632390 NPI number — KIDSPEACE CHILDREN'S HOSPITAL, INC.

Table of content: (NPI 1366632390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366632390 NPI number — KIDSPEACE CHILDREN'S HOSPITAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDSPEACE CHILDREN'S HOSPITAL, INC.
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:
1366632390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4085 INDEPENDENCE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHNECKSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18078-2574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-799-8525
Provider Business Mailing Address Fax Number:
610-799-8318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 PITTSTON AVE
Provider Second Line Business Practice Location Address:
FIRST FLOOR, SUITE 3
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18505-1150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-342-5444
Provider Business Practice Location Address Fax Number:
570-342-5539
Provider Enumeration Date:
07/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SLACK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
610-799-8405

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  201990 , 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: 100728370-0043 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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