1497846000 NPI number — WISHBONE ENTERPRISES LLC

Table of content: (NPI 1497846000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497846000 NPI number — WISHBONE ENTERPRISES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISHBONE ENTERPRISES LLC
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:
1497846000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
278 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUPONT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18641-1960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-655-8610
Provider Business Mailing Address Fax Number:
570-883-0488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
278 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUPONT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18641-1960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-655-8610
Provider Business Practice Location Address Fax Number:
570-883-0488
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KONICKI
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-655-8610

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PP410933L , 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: 1007440510002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3946893 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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