Provider Demographics
NPI:1275055873
Name:KEYSTONE RURAL HEALTH CENTER
Entity Type:Organization
Organization Name:KEYSTONE RURAL HEALTH CENTER
Other - Org Name:KEYSTONE DENTAL MONT ALTO
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-709-7922
Mailing Address - Street 1:111 CHAMBERS HILL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-7304
Mailing Address - Country:US
Mailing Address - Phone:717-709-7922
Mailing Address - Fax:717-261-4915
Practice Address - Street 1:6155 ANTHONY HWY STE C
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:PA
Practice Address - Zip Code:17268-9718
Practice Address - Country:US
Practice Address - Phone:717-765-8664
Practice Address - Fax:717-765-8663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100776233Medicaid