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General NPI Number Information
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NPI Number | 1609250976
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Entity Type | Organization
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Legal Business Name | SPIRTILIFE
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Dates
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Enumeration Date | 07/16/2015
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Last Update Date | 07/16/2015
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Provider Practice Location Address
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Address Line | 170 FR MARTIN TELENSON RD
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City | PENN RUN
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State | PA
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Zip | 15765-7336
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Country | US
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Telephone | 724-465-2165
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Fax |
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Provider Business Mailing Address
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Address Line | 170 FR MARTIN TELENSON RD
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City | PENN RUN
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State | PA
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Zip | 15765-7336
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Country | US
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Telephone | 724-465-2165
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | LOUIS E WAGNER
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Credential |
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Telephone | 724-465-2165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 327027
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License Number State | PA
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