MEDICARE: ALCOHOLISM AND DRUG SERVICES OF LOWER LUZERNE COUNTY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251V00000X	Voluntary or Charitable Agency	402249	PA

General Provider Information

NPI Number	:	1831193259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALCOHOLISM AND DRUG SERVICES OF LOWER LUZERNE COUNTY, INC.

Provider Business Mailing Address
First Line	:	145 W BROAD ST
Second Line	:	FL 2
City	:	HAZLETON
State	:	PA
Zip	:	18201-6500
Country	:	US
Telephone Number	:	570-455-9902
Fax Number	:	570-455-9452

Provider Business Practice Location Address
First Line	:	145 W BROAD ST
Second Line	:	FL 2
City	:	HAZLETON
State	:	PA
Zip	:	18201-6500
Country	:	US
Telephone Number	:	570-455-9902
Fax Number	:	570-455-9452

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	MR. EDWARD A. PANE
Credential	:	MBA, CAC
Telephone Number	:	570-455-9902

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	08/22/2020

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