Healthcare Provider Details

I. General information

NPI: 1033487780
Provider Name (Legal Business Name): MEDICAL TECHNICAL REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 ROUTE 22 HWY W
BLAIRSVILLE PA
15717-1264
US

IV. Provider business mailing address

1984 ROUTE 22 HWY W
BLAIRSVILLE PA
15717-1264
US

V. Phone/Fax

Practice location:
  • Phone: 724-459-4884
  • Fax: 724-459-4886
Mailing address:
  • Phone: 724-459-4884
  • Fax: 724-459-4886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number327022
License Number StatePA

VIII. Authorized Official

Name: THOMAS PLAITANO
Title or Position: CEO
Credential:
Phone: 724-834-1144