1942509328 NPI number — PHOENIX YOUTH SERVICES, INC.

Table of content: (NPI 1942509328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942509328 NPI number — PHOENIX YOUTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX YOUTH SERVICES, 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:
1942509328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
797 HARTFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHARPSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16150-9650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-646-1717
Provider Business Mailing Address Fax Number:
724-646-1770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
556 CONNEAUT LAKE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADAMSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-588-3425
Provider Business Practice Location Address Fax Number:
724-588-3811
Provider Enumeration Date:
03/24/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SEMBER
Authorized Official First Name:
DOMINIQUE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT/AED
Authorized Official Telephone Number:
724-699-3002

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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