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General NPI Number Information
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NPI Number | 1790908812
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Entity Type | Organization
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Legal Business Name | CLEM-MAR HOUSE, INC.
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 540 MAIN ST
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City | EDWARDSVILLE
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State | PA
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Zip | 18704-2504
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Country | US
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Telephone | 570-288-0403
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2028
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City | KINGSTON
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State | PA
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Zip | 18704-7038
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Country | US
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Telephone | 570-288-0403
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Fax |
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Authorized Official
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Title or Position | ASSISTANT PROJECT DIRECTOR
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Name | SONYA MOWRY
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Credential | BS, MS, CCMS, CCDP
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Telephone | 570-288-0403
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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 | 407043
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License Number State | PA
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