Provider Demographics
NPI:1275739955
Name:LYCOMING-CLINTON JOINDER BOARD
Entity Type:Organization
Organization Name:LYCOMING-CLINTON JOINDER BOARD
Other - Org Name:LYCOMING CLINTON MHMR PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:HUMAN SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIDOMENICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-323-6467
Mailing Address - Street 1:200 EAST ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6613
Mailing Address - Country:US
Mailing Address - Phone:570-326-0924
Mailing Address - Fax:570-326-1348
Practice Address - Street 1:200 EAST ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6613
Practice Address - Country:US
Practice Address - Phone:570-326-0924
Practice Address - Fax:570-326-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007332180012OtherCAPITATION