Provider Demographics
NPI:1366632390
Name:KIDSPEACE CHILDREN'S HOSPITAL, INC.
Entity Type:Organization
Organization Name:KIDSPEACE CHILDREN'S HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-799-8405
Mailing Address - Street 1:4085 INDEPENDENCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SCHNECKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18078-2574
Mailing Address - Country:US
Mailing Address - Phone:610-799-8525
Mailing Address - Fax:610-799-8318
Practice Address - Street 1:101 PITTSTON AVE
Practice Address - Street 2:FIRST FLOOR, SUITE 3
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-1150
Practice Address - Country:US
Practice Address - Phone:570-342-5444
Practice Address - Fax:570-342-5539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA201990251S00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100728370-0043Medicaid
PA100763290-0049Medicaid