1790808962 NPI number — CENTERVILLE CLINICS, INC.

Table of content: (NPI 1790808962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790808962 NPI number — CENTERVILLE CLINICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTERVILLE CLINICS, 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:
1790808962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1070 OLD NATIONAL PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15333-2114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-632-6801
Provider Business Mailing Address Fax Number:
724-632-6312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 SOUTH ARCH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONNELLSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-626-2630
Provider Business Practice Location Address Fax Number:
724-626-2655
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NICCOLAI
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
724-632-6801

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , 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: 1007288440037 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 391911 . This is a "NATIONAL GOVERNMENT SERVICES" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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