Basic Information
Provider Information | |||||||||
NPI: | 1497495634 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDRENS COMMUNITY CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 103 BRADFORD RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | WEXFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 150906910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7249331100 | ||||||||
FaxNumber: | 7249331160 | ||||||||
Practice Location | |||||||||
Address1: | 3512 STATE ROUTE 257 | ||||||||
Address2: |   | ||||||||
City: | SENECA | ||||||||
State: | PA | ||||||||
PostalCode: | 163462946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8146773717 | ||||||||
FaxNumber: | 8146778914 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2022 | ||||||||
LastUpdateDate: | 03/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTINEZ | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR III | ||||||||
AuthorizedOfficialTelephone: | 7249331100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.