1003172925 NPI number — SHARED SUPPORT, INC.

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 1003172925 NPI number — SHARED SUPPORT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHARED SUPPORT, 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:
1003172925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
218 BRIDGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNBURY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17801-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-286-4982
Provider Business Mailing Address Fax Number:
570-286-4984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 BRIDGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNBURY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17801-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-286-4982
Provider Business Practice Location Address Fax Number:
570-286-4984
Provider Enumeration Date:
04/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PRATT
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
FISCAL DIRECTOR
Authorized Official Telephone Number:
570-286-4982

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251K00000X , with the licence number: 329450 , 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: 101490123 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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