Basic Information
| Provider Information | |||||||||
| NPI: | 1952316705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAGE HOUSE, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2185 WEST 8TH STREET | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144648311 | ||||||||
| FaxNumber: | 8144648462 | ||||||||
| Practice Location | |||||||||
| Address1: | 1813 HOLLAND STREET | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148782100 | ||||||||
| FaxNumber: | 8148782104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | ERNST | ||||||||
| AuthorizedOfficialFirstName: | ANN MARIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR OF BILLING & ACCTS RECEI | ||||||||
| AuthorizedOfficialTelephone: | 8144648311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 257063 | PA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 413780 | 01 | PA | DEPT. OF WELFARE LICENSE | OTHER | 257063 | 01 | PA | DEPT. OF HEALTH LICENSE | OTHER |