Healthcare Provider Details

I. General information

NPI: 1902380793
Provider Name (Legal Business Name): KEYSTONE COMMUNITY RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 LINCOLN AVE
JERMYN PA
18433-1632
US

IV. Provider business mailing address

100 ABINGTON EXECUTIVE PARK STE B
CLARKS SUMMIT PA
18411-2276
US

V. Phone/Fax

Practice location:
  • Phone: 570-876-5056
  • Fax:
Mailing address:
  • Phone: 570-702-8000
  • Fax: 570-702-8196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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: MR. DAVID ANTHONY DAVITT JR.
Title or Position: ACCOUNTS RECEIVABLE COORDINATOR
Credential: DO
Phone: 570-702-8000