Basic Information
| Provider Information | |||||||||
| NPI: | 1245215268 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REDCO GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 S CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706285234 | ||||||||
| FaxNumber: | 5706289051 | ||||||||
| Practice Location | |||||||||
| Address1: | 16 S CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706285234 | ||||||||
| FaxNumber: | 5706289051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/30/2018 | ||||||||
| NPIReactivationDate: | 10/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | SOHOSKY | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5706285215 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 209010 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1000017170155 | 05 | PA | MEDICAID |