Provider Demographics
NPI:1043674351
Name:PROSPECT CCMC, LLC
Entity Type:Organization
Organization Name:PROSPECT CCMC, LLC
Other - Org Name:NEW PATHWAYS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JON
Authorized Official - Last Name:ELDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-788-1249
Mailing Address - Street 1:100 CROZERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ASTON
Mailing Address - State:PA
Mailing Address - Zip Code:19014-1444
Mailing Address - Country:US
Mailing Address - Phone:610-447-2000
Mailing Address - Fax:610-447-6620
Practice Address - Street 1:100 CROZERVILLE RD
Practice Address - Street 2:
Practice Address - City:ASTON
Practice Address - State:PA
Practice Address - Zip Code:19014-1444
Practice Address - Country:US
Practice Address - Phone:610-447-2000
Practice Address - Fax:610-447-6620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center