Healthcare Provider Details

I. General information

NPI: 1174615686
Provider Name (Legal Business Name): KEYSTONE RURAL HEALTH CONSORTIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 EAST SYCAMORE STREET
SNOW SHOE PA
16874-0402
US

IV. Provider business mailing address

90 EAST SECOND STREET
EMPORIUM PA
15834-1302
US

V. Phone/Fax

Practice location:
  • Phone: 814-387-6857
  • Fax: 814-387-6870
Mailing address:
  • Phone: 814-486-1115
  • Fax: 814-486-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD G HAMMERSLEY
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 814-486-1115