Healthcare Provider Details

I. General information

NPI: 1346266087
Provider Name (Legal Business Name): FSLJC, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 MEMORIAL HWY
SHAVERTOWN PA
18708-1482
US

IV. Provider business mailing address

1845 MEMORIAL HWY
SHAVERTOWN PA
18708-1482
US

V. Phone/Fax

Practice location:
  • Phone: 570-674-6525
  • Fax: 570-674-6520
Mailing address:
  • Phone: 570-674-6525
  • Fax: 570-674-6520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN J COLLINI
Title or Position: ADMINISTRATOR
Credential: RT (R) RDMS RDCS
Phone: 570-674-6525