1518088160 NPI number — HARBORCREEK YOUTH SERVICES

Table of content: (NPI 1518088160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518088160 NPI number — HARBORCREEK YOUTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARBORCREEK YOUTH SERVICES
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:
1518088160
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:
5712 IROQUOIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARBORCREEK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16421-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-899-7664
Provider Business Mailing Address Fax Number:
814-899-3075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1052 W 26TH ST
Provider Second Line Business Practice Location Address:
WEST 26TH STREET HOUSE
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16508-1516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-459-5629
Provider Business Practice Location Address Fax Number:
814-461-1539
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PETULLA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
814-899-7664

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X , with the licence number:  433380 , 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: 001410380 0018 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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