1740282144 NPI number — JOHN XXIII HOME

Table of content: (NPI 1740282144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740282144 NPI number — JOHN XXIII HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN XXIII HOME
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:
1740282144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2250 SHENANGO VALLEY FWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMITAGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16148-2549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-981-3200
Provider Business Mailing Address Fax Number:
724-981-1677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 SHENANGO VALLEY FWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMITAGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16148-2549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-981-3200
Provider Business Practice Location Address Fax Number:
724-981-1677
Provider Enumeration Date:
08/15/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HAWTHORNE
Authorized Official First Name:
KIRK
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
724-981-3200

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  360202 , 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: 0994 . This is a "HIGHMARK SECURITY BLUE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0007473280001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".