=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043553696
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASTERY CHARTER HARDY WILLIAMS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2013
-----------------------------------------------------
Last Update Date | 04/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1712 S 56TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19143-5308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-724-2343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5700 WAYNE AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19144-3314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-866-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCESS COORDINATOR
-----------------------------------------------------
Name | MONICA BROWN
-----------------------------------------------------
Credential | M.S.A
-----------------------------------------------------
Telephone | 215-866-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number | 126513290
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------