Basic Information
| Provider Information | |||||||||
| NPI: | 1366806663 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROSPECT CCMC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY SCHOOL #83 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19014 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106198700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2016 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELDERS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JON | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 7147881249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.