Basic Information
Provider Information | |||||||||
NPI: | 1003913955 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH PENN COMPREHENSIVE HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ELKLAND LAUREL HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6A RIVERSIDE PLZ | ||||||||
Address2: |   | ||||||||
City: | BLOSSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 169121137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5706621945 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 103 FORESTVIEW AVE | ||||||||
Address2: |   | ||||||||
City: | ELKLAND | ||||||||
State: | PA | ||||||||
PostalCode: | 169201403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8142585117 | ||||||||
FaxNumber: | 8142585510 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 06/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VANZILE | ||||||||
AuthorizedOfficialFirstName: | ANGELA | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 5706621945 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1000011720036 | 05 | PA |   | MEDICAID |