Provider Demographics
NPI:1407141930
Name:FOUNDATION HEALTHCARE LLC
Entity Type:Organization
Organization Name:FOUNDATION HEALTHCARE LLC
Other - Org Name:CEDAR RESIDENCE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALKO
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:215-718-9702
Mailing Address - Street 1:201 S. BLAKELY ST. #176
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512
Mailing Address - Country:US
Mailing Address - Phone:570-955-3260
Mailing Address - Fax:570-504-7278
Practice Address - Street 1:929 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-1723
Practice Address - Country:US
Practice Address - Phone:570-955-3260
Practice Address - Fax:570-504-7278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA357038324500000X
PA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102615859Medicaid