Healthcare Provider Details

I. General information

NPI: 1336302017
Provider Name (Legal Business Name): KENSINGTON HOSPITAL- INTENSIVE OUTPATIENT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 DIAMOND ST
PHILADELPHIA PA
19122-1721
US

IV. Provider business mailing address

136 DIAMOND ST
PHILADELPHIA PA
19122-1721
US

V. Phone/Fax

Practice location:
  • Phone: 215-426-8100
  • Fax: 215-965-2344
Mailing address:
  • Phone: 215-426-8100
  • Fax: 215-965-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number807340
License Number StatePA

VIII. Authorized Official

Name: MS. EILEEN HAUSE
Title or Position: CEO
Credential: MBA
Phone: 215-426-8100