Healthcare Provider Details

I. General information

NPI: 1801884432
Provider Name (Legal Business Name): LAUREL CREST DME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 MANOR DR
EBENSBURG PA
15931-4917
US

IV. Provider business mailing address

429 MANOR DR
EBENSBURG PA
15931-4917
US

V. Phone/Fax

Practice location:
  • Phone: 814-472-8100
  • Fax: 814-471-2131
Mailing address:
  • Phone: 814-472-8100
  • Fax: 814-471-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number6000004896
License Number StatePA

VIII. Authorized Official

Name: MRS. NANCY J. MCMAHON
Title or Position: ASST. FINANCIAL OFFICER
Credential:
Phone: 814-472-8100