Basic Information
| Provider Information | |||||||||
| NPI: | 1871839688 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINTON HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HAVEN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657488 | ||||||||
| FaxNumber: | 6154696505 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 E CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LOCK HAVEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177452025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707480590 | ||||||||
| FaxNumber: | 5707480596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2012 | ||||||||
| LastUpdateDate: | 04/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | TARA | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6152213672 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLINTON HOSPITAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 122201 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1007550910020 | 05 | PA | MEDICAID |