1609253301 NPI number — COMMUNITY DIABETES AND NUTRITION SERVICES, LLC

Table of content: (NPI 1609253301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609253301 NPI number — COMMUNITY DIABETES AND NUTRITION SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY DIABETES AND NUTRITION SERVICES, 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:
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:
1609253301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MAIN ST
Provider Second Line Business Mailing Address:
SUITE L4
Provider Business Mailing Address City Name:
BLAKELY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18447-1241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-604-6677
Provider Business Mailing Address Fax Number:
570-307-4220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE L4
Provider Business Practice Location Address City Name:
BLAKELY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18447-1241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-604-6677
Provider Business Practice Location Address Fax Number:
570-307-4220
Provider Enumeration Date:
05/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
TAKACS
Authorized Official First Name:
ROSEMARY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER AND PROGRAM COORDINATOR
Authorized Official Telephone Number:
570-604-6677

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DN000285 , 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: 1306930847 . This is a "BLUE CROSS OF NORTHEAST PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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