Provider Demographics
NPI:1427471044
Name:PA INNER VISION
Entity type:Organization
Organization Name:PA INNER VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-476-1902
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE ON DELAWARE
Mailing Address - State:PA
Mailing Address - Zip Code:18356-0172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:586 MAIN ST
Practice Address - Street 2:SUITE 9
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2004
Practice Address - Country:US
Practice Address - Phone:570-476-1902
Practice Address - Fax:570-476-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA457035324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility