1033148630 NPI number — DIAKON LUTHERAN SOCIAL MINISTRIES

Table of content: (NPI 1033148630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033148630 NPI number — DIAKON LUTHERAN SOCIAL MINISTRIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAKON LUTHERAN SOCIAL MINISTRIES
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:
6
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:
1033148630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
435 W 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSPORT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17701-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-322-7873
Provider Business Mailing Address Fax Number:
570-322-8026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 MONTOUR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOYSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17047-9200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-795-0330
Provider Business Practice Location Address Fax Number:
717-795-0407
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROUSSEAU
Authorized Official First Name:
RITA
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR COS
Authorized Official Telephone Number:
717-795-0368

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1526223 . This is a "PA BLUE SHIELD - CRNP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007777400059 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02319100 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 301029 . This is a "VALUEOPTIONS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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