Provider Demographics
NPI:1386082154
Name:CMSU MH/MR AND D&A PROGRAM
Entity type:Organization
Organization Name:CMSU MH/MR AND D&A PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:T
Authorized Official - Last Name:KEATING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-275-5422
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-0219
Mailing Address - Country:US
Mailing Address - Phone:570-275-5422
Mailing Address - Fax:570-275-6610
Practice Address - Street 1:460 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1592
Practice Address - Country:US
Practice Address - Phone:570-387-1132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA326360385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA191259OtherCOUNTY FUNDED