Healthcare Provider Details

I. General information

NPI: 1871739151
Provider Name (Legal Business Name): WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 PARK ST
HONESDALE PA
18431-1446
US

IV. Provider business mailing address

601 PARK ST
HONESDALE PA
18431-1445
US

V. Phone/Fax

Practice location:
  • Phone: 570-253-3005
  • Fax: 570-253-0181
Mailing address:
  • Phone: 570-253-3005
  • Fax: 570-253-0181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: FREDERICK JACKSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 570-253-8450