Healthcare Provider Details

I. General information

NPI: 1275135873
Provider Name (Legal Business Name): CHILDEN'S COMMUNITY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 ROTH CHURCH RD
SPRING GROVE PA
17362-1406
US

IV. Provider business mailing address

103 BRADFORD RD STE 200
WEXFORD PA
15090-6910
US

V. Phone/Fax

Practice location:
  • Phone: 717-757-3400
  • Fax: 717-757-3702
Mailing address:
  • Phone: 724-933-1100
  • Fax: 724-933-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LORI MARTINEZ
Title or Position: EXECUTIVE ADMINISTRATOR III
Credential:
Phone: 724-933-1100