Basic Information
| Provider Information | |||||||||
| NPI: | 1861531147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONGRESO DE LATINOS UNIDOS- ESFUERZO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 216 W SOMERSET ST | ||||||||
| Address2: | ESFUERZO PROGRAM | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191333534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157638870 | ||||||||
| FaxNumber: | 2152232936 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 W SOMERSET ST | ||||||||
| Address2: | ESFUERZO PROGRAM | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191333534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157638870 | ||||||||
| FaxNumber: | 2152232936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 09/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | MALDONADO | ||||||||
| AuthorizedOfficialFirstName: | WALESKA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF PROGRAM OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2157638870 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 100751904 | PA | Y | Agencies | Case Management |
No ID Information.