Healthcare Provider Details

I. General information

NPI: 1104284751
Provider Name (Legal Business Name): COMMUNITY HEALTH CARE RURAL HEALTH CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W WALNUT ST
SHAMOKIN PA
17872-5226
US

IV. Provider business mailing address

550 W WALNUT ST
SHAMOKIN PA
17872-5226
US

V. Phone/Fax

Practice location:
  • Phone: 570-644-2222
  • Fax: 570-648-4705
Mailing address:
  • Phone: 570-644-2222
  • Fax: 570-648-4705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. NADINE MARKOVICH-STEN
Title or Position: MEMBER / ADMINISTRATIVE DIRECTOR
Credential: PA-C
Phone: 570-644-2222