1942503560 NPI number — DEMENTIA CONNECTION LLC

Table of content: (NPI 1942503560)

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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