Provider Demographics
NPI:1043434608
Name:GAUDENZIA DRC INC
Entity Type:Organization
Organization Name:GAUDENZIA DRC INC
Other - Org Name:GAUDENZIA DRC OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIR. FISCAL & CORPORATE OPERASTIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:610-239-9600
Mailing Address - Street 1:106 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401-4716
Mailing Address - Country:US
Mailing Address - Phone:610-239-9600
Mailing Address - Fax:610-275-7025
Practice Address - Street 1:3200 HENRY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1137
Practice Address - Country:US
Practice Address - Phone:215-991-9700
Practice Address - Fax:215-991-9796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA807384261Q00000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019613780008Medicaid