Healthcare Provider Details

I. General information

NPI: 1467759399
Provider Name (Legal Business Name): PENNSYLVANIA CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 S MAIN ST
ASHLEY PA
18706-1506
US

IV. Provider business mailing address

1317 ROUTE 73 STE 200
MOUNT LAUREL NJ
08054-2202
US

V. Phone/Fax

Practice location:
  • Phone: 570-822-5145
  • Fax: 570-822-5147
Mailing address:
  • Phone: 856-429-6111
  • Fax: 570-822-5147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number407058
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBYN TANIS
Title or Position: EXECUTIVE DIRECTOR OF CONTRACT MGMT
Credential:
Phone: 856-533-8762