Healthcare Provider Details

I. General information

NPI: 1073842936
Provider Name (Legal Business Name): WILKES BARRE BEHAVIORAL HOSPITAL COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 WYOMING AVE
KINGSTON PA
18704-3721
US

IV. Provider business mailing address

562 WYOMING AVE
KINGSTON PA
18704-3721
US

V. Phone/Fax

Practice location:
  • Phone: 570-552-3700
  • Fax: 570-552-3733
Mailing address:
  • Phone: 570-552-3700
  • Fax: 570-552-3733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: LAURIE HOLTSFORD
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 615-465-7466