=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750559811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTERVILLE CLINICS, INC CHARLEROI MH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2008
-----------------------------------------------------
Last Update Date | 02/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 MCKEAN AVE
-----------------------------------------------------
City | CHARLEROI
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15022-1558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-483-5482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1070 OLD NATIONAL PIKE
-----------------------------------------------------
City | FREDERICKTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15333-2114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-632-6801
-----------------------------------------------------
Fax | 724-632-6312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR FINANCE AND PERSONNEL
-----------------------------------------------------
Name | MRS. PATRICIA MARTOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-632-6801
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------