Provider Demographics
NPI:1417132580
Name:CENTERVILLE CLINICS, INC BLENDED
Entity Type:Organization
Organization Name:CENTERVILLE CLINICS, INC BLENDED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR FINANCE/PERSONNEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-632-6801
Mailing Address - Street 1:1070 OLD NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:601 W GEORGE ST
Practice Address - Street 2:
Practice Address - City:CARMICHAELS
Practice Address - State:PA
Practice Address - Zip Code:15320-1325
Practice Address - Country:US
Practice Address - Phone:724-966-5081
Practice Address - Fax:724-966-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA328834A764918OtherVALUE BEHAVIOR HEALTH
PA1007288440093Medicaid