Provider Demographics
NPI:1386884831
Name:LUZERNE/WYOMING COUNTY MH CENTER #1
Entity type:Organization
Organization Name:LUZERNE/WYOMING COUNTY MH CENTER #1
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER/MIS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:PIAZZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-552-3625
Mailing Address - Street 1:562 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3721
Mailing Address - Country:US
Mailing Address - Phone:570-552-3625
Mailing Address - Fax:570-552-3907
Practice Address - Street 1:110 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3301
Practice Address - Country:US
Practice Address - Phone:570-552-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUZERNE/WYOMING COUNTY MH CENTER #1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100002080Medicaid