1386922714 NPI number — ESPERANZA HEALTH CENTER INC

Table of content: (NPI 1386922714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386922714 NPI number — ESPERANZA HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESPERANZA HEALTH CENTER 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:
1386922714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4417 N. 6TH ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19140-2319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-302-3600
Provider Business Mailing Address Fax Number:
215-807-8395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4417 N. 6TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19140-2319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-302-3600
Provider Business Practice Location Address Fax Number:
215-329-2369
Provider Enumeration Date:
08/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DEEM
Authorized Official First Name:
GLENNA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
215-302-3600

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1007734560009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 153891 . This is a "MEDICARE PART B PTAN" identifier . This identifiers is of the category "OTHER".




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