Provider Demographics
NPI:1659601979
Name:NORTHEAST PENNSYLVANIA CENTER FOR INDEPENDENT LIVING
Entity type:Organization
Organization Name:NORTHEAST PENNSYLVANIA CENTER FOR INDEPENDENT LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-344-7211
Mailing Address - Street 1:1142 SANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2623
Mailing Address - Country:US
Mailing Address - Phone:570-344-7211
Mailing Address - Fax:570-558-5570
Practice Address - Street 1:1142 SANDERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-2623
Practice Address - Country:US
Practice Address - Phone:570-344-7211
Practice Address - Fax:570-558-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251X00000XAgenciesSupports BrokerageGroup - Multi-Specialty
No171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88931382Medicaid
PA100680698Medicaid
WYAPPLIED FORMedicaid