Basic Information
| Provider Information | |||||||||
| NPI: | 1376526111 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TORRANCE STATE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | STATE ROUTE 1014 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157790111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244594511 | ||||||||
| FaxNumber: | 7244594498 | ||||||||
| Practice Location | |||||||||
| Address1: | STATE ROUTE 1014 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157790111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244594511 | ||||||||
| FaxNumber: | 7244594498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIGHT | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7177722518 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100308518 | 05 | PA | MEDICAID |