Provider Demographics
NPI:1356486062
Name:INTERCOMMUNITY ACTION, INC
Entity Type:Organization
Organization Name:INTERCOMMUNITY ACTION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-487-0906
Mailing Address - Street 1:6012 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1643
Mailing Address - Country:US
Mailing Address - Phone:215-487-0906
Mailing Address - Fax:
Practice Address - Street 1:535 SHAWMONT AVE
Practice Address - Street 2:SHAWMONT SCHOOL
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19128-4032
Practice Address - Country:US
Practice Address - Phone:215-508-6710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000008360092Medicaid