1205957693 NPI number — LUZERNE WYOMING COUNTY MH CENTER #1

Table of content: (NPI 1205957693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205957693 NPI number — LUZERNE WYOMING COUNTY MH CENTER #1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUZERNE WYOMING COUNTY MH CENTER #1
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:
1205957693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
562 WYOMING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-3721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-552-3900
Provider Business Mailing Address Fax Number:
570-552-3907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 BRIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUNKHANNOCK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18657-1303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-836-3118
Provider Business Practice Location Address Fax Number:
570-836-1117
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KNECHT
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
570-552-3900

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100002080-0005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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