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General NPI Number Information
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NPI Number | 1053560623
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Entity Type | Organization
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Legal Business Name | CCP
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Dates
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Enumeration Date | 09/18/2008
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Last Update Date | 09/18/2008
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Provider Practice Location Address
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Address Line | 410 9TH ST
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City | NEW KENSINGTON
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State | PA
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Zip | 15068-6406
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Country | US
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Telephone | 724-337-3591
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Fax | 724-337-3592
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Provider Business Mailing Address
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Address Line | 410 9TH ST
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City | NEW KENSINGTON
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State | PA
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Zip | 15068-6406
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Country | US
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Telephone | 724-337-3591
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Fax | 724-337-3592
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Authorized Official
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Title or Position | ADMIN
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Name | MRS. CARMEN M PACK
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Credential | NURSE
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Telephone | 724-337-3591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | P-N093516-L
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License Number State | PA
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