Provider Demographics
NPI:1386922714
Name:ESPERANZA HEALTH CENTER INC
Entity type:Organization
Organization Name:ESPERANZA HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-302-3600
Mailing Address - Street 1:4417 N. 6TH ST.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-2319
Mailing Address - Country:US
Mailing Address - Phone:215-302-3600
Mailing Address - Fax:215-807-8395
Practice Address - Street 1:4417 N. 6TH ST.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2319
Practice Address - Country:US
Practice Address - Phone:215-302-3600
Practice Address - Fax:215-329-2369
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESPERANZA HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-03
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007734560009Medicaid
153891OtherMEDICARE PART B PTAN
PA391019Medicare PIN