Basic Information
| Provider Information | |||||||||
| NPI: | 1144378530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENSINGTON HOSPITAL INPATIENT NON-HOSPITAL DETOXIFICATION | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 136 DIAMOND ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191221721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154268100 | ||||||||
| FaxNumber: | 2159652344 | ||||||||
| Practice Location | |||||||||
| Address1: | 136 DIAMOND ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191221721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154268100 | ||||||||
| FaxNumber: | 2159652344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAUSE | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2154268100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.B.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 860231 | PA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1007717290016 | 05 | PA | MEDICAID |