Healthcare Provider Details

I. General information

NPI: 1760610117
Provider Name (Legal Business Name): THE KING'S HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 06/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 N AMERICAN ST
PHILADELPHIA PA
19140-5701
US

IV. Provider business mailing address

3509 N AMERICAN ST
PHILADELPHIA PA
19140-5701
US

V. Phone/Fax

Practice location:
  • Phone: 267-639-5185
  • Fax: 267-639-5189
Mailing address:
  • Phone: 267-639-5185
  • Fax: 267-639-5189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number807409
License Number StatePA

VIII. Authorized Official

Name: MR. PAUL AZZINARO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 267-639-5185