Provider Demographics
NPI:1194377341
Name:WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Other - Org Name:STERLING PEDIATRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-253-8450
Mailing Address - Street 1:601 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:570-253-8226
Mailing Address - Fax:
Practice Address - Street 1:62 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:LAKE ARIEL
Practice Address - State:PA
Practice Address - Zip Code:18436-5606
Practice Address - Country:US
Practice Address - Phone:570-689-7565
Practice Address - Fax:570-689-4803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-09
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty