Healthcare Provider Details

I. General information

NPI: 1932181047
Provider Name (Legal Business Name): CENTERVILLE CLINICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 MAIN STREET
REPUBLIC PA
15475
US

IV. Provider business mailing address

1070 OLD NATIONAL PIKE
FREDERICKTOWN PA
15333-2114
US

V. Phone/Fax

Practice location:
  • Phone: 724-246-9434
  • Fax: 724-246-9846
Mailing address:
  • Phone: 724-632-6801
  • Fax: 724-632-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA MARTOS
Title or Position: DIRECTOR FINANCE/PERSONNEL
Credential:
Phone: 724-632-6801