Provider Demographics
NPI:1093830226
Name:GEORGE JUNIOR REPUBLIC IN PENNSYLVANIA
Entity Type:Organization
Organization Name:GEORGE JUNIOR REPUBLIC IN PENNSYLVANIA
Other - Org Name:J COTTAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOSASSO
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:724-458-9330
Mailing Address - Street 1:PO BOX 1058
Mailing Address - Street 2:233 GEORGE JUNIOR ROAD
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-5058
Mailing Address - Country:US
Mailing Address - Phone:724-458-9330
Mailing Address - Fax:724-458-0389
Practice Address - Street 1:233 GEORGE JUNIOR ROAD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127
Practice Address - Country:US
Practice Address - Phone:724-458-9330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014522190038Medicaid