Provider Demographics
NPI:1063794634
Name:CENTERVILLE CLINICS, INC.
Entity type:Organization
Organization Name:CENTERVILLE CLINICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR FINANCE PERSONNEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-632-6801
Mailing Address - Street 1:1070 OLD NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:75 BEARCAT DR
Practice Address - Street 2:
Practice Address - City:BENTLEYVILLE
Practice Address - State:PA
Practice Address - Zip Code:15314-1421
Practice Address - Country:US
Practice Address - Phone:724-632-6801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA438860251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA438860OtherCERTIFICATE OF COMPLIANCE