1902159619 NPI number — WAYNE MEMORIAL COMMUNITY HEALTH CENTERS

Table of content: (NPI 1902159619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902159619 NPI number — WAYNE MEMORIAL COMMUNITY HEALTH CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
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:
CARBONDALE FAMILY HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1902159619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 PARK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONESDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18431-1445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-251-6641
Provider Business Mailing Address Fax Number:
570-253-8228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 BROOKLYN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18407-2274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-282-2031
Provider Business Practice Location Address Fax Number:
570-282-2534
Provider Enumeration Date:
10/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LACEY
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
570-253-8451

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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