1396881322 NPI number — COMMUNITY LIFE SUPPORT SYSTEMS, INC.

Table of content: (NPI 1396881322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396881322 NPI number — COMMUNITY LIFE SUPPORT SYSTEMS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY LIFE SUPPORT SYSTEMS, 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:
1396881322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 472
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKS SUMMIT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18411-0472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-586-0611
Provider Business Mailing Address Fax Number:
570-585-6906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 ABINGTON EXECUTIVE PARK STE 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKS SUMMIT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18411-2269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-586-0611
Provider Business Practice Location Address Fax Number:
570-585-6906
Provider Enumeration Date:
01/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROWLAND
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
570-586-0611

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  05096 , 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: 290545 . This is a "ACCESS CARE BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 998577 . This is a "BC NEPA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 800743 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 00015749640002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".