Healthcare Provider Details

I. General information

NPI: 1023153616
Provider Name (Legal Business Name): INTERCOMMUNITY ACTION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 W BUTLER ST
PHILADELPHIA PA
19140
US

IV. Provider business mailing address

6012 RIDGE AVE
PHILA PA
19128-1643
US

V. Phone/Fax

Practice location:
  • Phone: 215-508-6710
  • Fax:
Mailing address:
  • Phone: 215-487-0906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DAVID BOLIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 215-487-0906