Healthcare Provider Details

I. General information

NPI: 1548691785
Provider Name (Legal Business Name): CHILDREN'S COMMUNITY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 HOSPITAL DR LOWR LEVEL
EVERETT PA
15537-7020
US

IV. Provider business mailing address

103 BRADFORD RD STE 200
WEXFORD PA
15090-6910
US

V. Phone/Fax

Practice location:
  • Phone: 814-623-9039
  • Fax: 814-623-0355
Mailing address:
  • Phone: 724-933-1100
  • Fax: 724-933-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LORI MARTINEZ
Title or Position: EXECUTIVE ADMINSTRATOR III
Credential:
Phone: 724-933-1100