Provider Demographics
NPI:1245804483
Name:KEYSTONE COMMUNITY RESOURCES INC.
Entity Type:Organization
Organization Name:KEYSTONE COMMUNITY RESOURCES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DAVITT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:570-702-8000
Mailing Address - Street 1:100 ABINGTON EXECUTIVE PARK STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2276
Mailing Address - Country:US
Mailing Address - Phone:570-702-8000
Mailing Address - Fax:570-702-8196
Practice Address - Street 1:900 GIBBONS ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-3614
Practice Address - Country:US
Practice Address - Phone:570-207-1908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON SERVICES HOLDINGS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0598747Medicaid