Healthcare Provider Details

I. General information

NPI: 1780062877
Provider Name (Legal Business Name): LYCOMING PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PIERCE ST SUITE 103
KINGSTON PA
18704-5149
US

IV. Provider business mailing address

1111 E 3RD ST
WILLIAMSPORT PA
17701-5411
US

V. Phone/Fax

Practice location:
  • Phone: 570-916-4897
  • Fax:
Mailing address:
  • Phone: 570-326-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberMD045007L
License Number StatePA

VIII. Authorized Official

Name: DR. MARK ALLEN HAMPTON
Title or Position: CEO
Credential: D.C.
Phone: 570-326-0400