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General NPI Number Information
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NPI Number | 1477669901
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Entity Type | Organization
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Legal Business Name | CLEARBROOK FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 08/21/2006
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Last Update Date | 10/13/2010
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Provider Practice Location Address
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Address Line | 863 S LINCOLN AVE
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City | TYRONE
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State | PA
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Zip | 16686-1349
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Country | US
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Telephone | 814-684-1245
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Fax | 814-684-1246
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Provider Business Mailing Address
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Address Line | 863 S LINCOLN AVE
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City | TYRONE
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State | PA
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Zip | 16686-1349
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Country | US
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Telephone | 814-684-1245
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Fax | 814-684-1246
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | JASON E HENNINGER
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Credential | D.O.
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Telephone | 814-684-1245
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS009583L
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License Number State | PA
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