Healthcare Provider Details

I. General information

NPI: 1821380361
Provider Name (Legal Business Name): JON C DESANTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CALDWELL DR
DU BOIS PA
15801-1152
US

IV. Provider business mailing address

793 OLD ROUTE 119 HWY N
INDIANA PA
15701-1372
US

V. Phone/Fax

Practice location:
  • Phone: 814-371-1100
  • Fax: 814-375-0120
Mailing address:
  • Phone: 724-465-5576
  • Fax: 724-465-6379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: