Provider Demographics
NPI:1144378530
Name:KENSINGTON HOSPITAL INPATIENT NON-HOSPITAL DETOXIFICATION
Entity Type:Organization
Organization Name:KENSINGTON HOSPITAL INPATIENT NON-HOSPITAL DETOXIFICATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:215-426-8100
Mailing Address - Street 1:136 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122-1721
Mailing Address - Country:US
Mailing Address - Phone:215-426-8100
Mailing Address - Fax:215-965-2344
Practice Address - Street 1:136 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-1721
Practice Address - Country:US
Practice Address - Phone:215-426-8100
Practice Address - Fax:215-965-2344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA860231251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007717290016Medicaid