Healthcare Provider Details

I. General information

NPI: 1134341704
Provider Name (Legal Business Name): INTERCOMMUNITY ACTION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 GATES ST
PHILADELPHIA PA
19128-4618
US

IV. Provider business mailing address

4120 TOWER ST
PHILADELPHIA PA
19127-1721
US

V. Phone/Fax

Practice location:
  • Phone: 215-487-3150
  • Fax:
Mailing address:
  • Phone: 215-487-3150
  • 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