Basic Information
| Provider Information | |||||||||
| NPI: | 1265419998 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE REDCO GROUP, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 S. CENTRE STREET | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706285234 | ||||||||
| FaxNumber: | 5706289051 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 W MARKET ST | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179012810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706284731 | ||||||||
| FaxNumber: | 5705169448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | SOHOSKY | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5706285215 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 203370 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1000017170526 | 05 | PA | MEDICAID |