1629702550 NPI number — TWIN LAKES CENTER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629702550 NPI number — TWIN LAKES CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN LAKES CENTER 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:
1629702550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 TWIN LAKES ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15501-7727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-443-3639
Provider Business Mailing Address Fax Number:
814-443-2737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 S PLEASANT AVENUE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15501-2196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-443-3639
Provider Business Practice Location Address Fax Number:
814-443-2737
Provider Enumeration Date:
07/15/2022

Additional Information

Authorized Official

Authorized Official Last Name:
CANNON
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, CLINICAL SERVICES
Authorized Official Telephone Number:
814-443-3639

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100773311 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com