Healthcare Provider Details

I. General information

NPI: 1659601979
Provider Name (Legal Business Name): NORTHEAST PENNSYLVANIA CENTER FOR INDEPENDENT LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 SANDERSON AVE
SCRANTON PA
18509-2623
US

IV. Provider business mailing address

1142 SANDERSON AVE
SCRANTON PA
18509-2623
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-7211
  • Fax: 570-558-5570
Mailing address:
  • Phone: 570-344-7211
  • Fax: 570-558-5570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier88931382
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 2
Identifier100680698
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
IdentifierAPPLIED FOR
Identifier TypeMEDICAID
Identifier StateWY
Identifier Issuer

VIII. Authorized Official

Name: HELEN LOGAN
Title or Position: DIRECTOR OF ACCOUNTING
Credential:
Phone: 570-344-7211