MEDICARE: DIAKON LUTHERAN SOCIAL MINISTRIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568491165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAKON LUTHERAN SOCIAL MINISTRIES

Provider Business Mailing Address
First Line	:	435 W 4TH ST
Second Line	:
City	:	WILLIAMSPORT
State	:	PA
Zip	:	17701-6001
Country	:	US
Telephone Number	:	570-322-7873
Fax Number	:	570-322-8026

Provider Business Practice Location Address
First Line	:	571 MOUNTAIN RD # 10
Second Line	:
City	:	BOILING SPRINGS
State	:	PA
Zip	:	17007-9520
Country	:	US
Telephone Number	:	717-795-0330
Fax Number	:	717-795-0407

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR COS
Name	:	RITA A. ROUSSEAU
Credential	:
Telephone Number	:	717-795-0368

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	10/25/2007

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