Healthcare Provider Details

I. General information

NPI: 1407075245
Provider Name (Legal Business Name): INTERCOMMUNITY ACTION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 N 54TH ST
PHILADELPHIA PA
19131-2423
US

IV. Provider business mailing address

6012 RIDGE AVE
PHILADELPHIA PA
19128-1643
US

V. Phone/Fax

Practice location:
  • Phone: 215-477-6661
  • Fax:
Mailing address:
  • Phone: 215-487-0906
  • Fax: 215-487-3716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

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