1396880746 NPI number — GREBLAW INC

Table of content: (NPI 1396880746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396880746 NPI number — GREBLAW INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREBLAW 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:
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:
1396880746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 CONNEAUT LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16125-2167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-885-0310
Provider Business Mailing Address Fax Number:
724-885-0330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 LIBERTY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16134-0395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-932-5355
Provider Business Practice Location Address Fax Number:
724-932-3943
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALBERG
Authorized Official First Name:
BRETTON
Authorized Official Middle Name:
CLARK
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
724-612-2131

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PP413647L , 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: 17752920001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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