Healthcare Provider Details

I. General information

NPI: 1528928389
Provider Name (Legal Business Name): 2309 STAFFORD AVENUE OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 STAFFORD AVE
SCRANTON PA
18505-3686
US

IV. Provider business mailing address

5 EVES DR
MARLTON NJ
08053-3135
US

V. Phone/Fax

Practice location:
  • Phone: 856-282-5590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: JENNIFER MELLON
Title or Position: VP COMPLIANCE
Credential:
Phone: 856-282-5590