MEDICARE: KEYSTONE COMMUNITY RESOURCES, INC.

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	CER-00128996	PA

General Provider Information

NPI Number	:	1669953642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEYSTONE COMMUNITY RESOURCES, INC.

Provider Business Mailing Address
First Line	:	100 ABINGTON EXECUTIVE PARK STE B
Second Line	:
City	:	CLARKS SUMMIT
State	:	PA
Zip	:	18411-2276
Country	:	US
Telephone Number	:	570-702-8000
Fax Number	:	570-702-8196

Provider Business Practice Location Address
First Line	:	767 STATE ROUTE 307
Second Line	:
City	:	SPRING BROOK TOWNSHIP
State	:	PA
Zip	:	18444-6463
Country	:	US
Telephone Number	:	570-842-9395
Fax Number	:

Authorized Official
Title or Position	:	ACCOUNTS RECEIVABLE COORDINATOR
Name	:	MR. DAVID ANTHONY DAVITT
Credential	:	DO
Telephone Number	:	570-702-8000

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	02/07/2020

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