1942503560 NPI number — DEMENTIA CONNECTION LLC

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 1942503560 NPI number — DEMENTIA CONNECTION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEMENTIA CONNECTION 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:
1942503560
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 APPLE VALLEY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH ABINGTON TOWNSHIP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18411-9498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-586-0655
Provider Business Mailing Address Fax Number:
570-586-5174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 ADAMS AVE
Provider Second Line Business Practice Location Address:
HOLY FAMILY RESIDENCE
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18509-1515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-343-4065
Provider Business Practice Location Address Fax Number:
570-343-0448
Provider Enumeration Date:
12/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SCANLAND
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
CEO AND FOUNDER
Authorized Official Telephone Number:
570-586-0655

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  VP000593C , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: SP010872 , 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: 1583600PABS . This is a "PA BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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