Provider Demographics
NPI:1467677831
Name:NULTON DIAGNOSTIC AND TREATMENT CENTER
Entity Type:Organization
Organization Name:NULTON DIAGNOSTIC AND TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NULTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-262-0025
Mailing Address - Street 1:220 COLLEGE PARK PLAZA
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904
Mailing Address - Country:US
Mailing Address - Phone:814-266-0025
Mailing Address - Fax:814-266-8745
Practice Address - Street 1:220 COLLEGE PARK PLAZA
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904
Practice Address - Country:US
Practice Address - Phone:814-266-0025
Practice Address - Fax:814-266-8745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA313430251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007324900004Medicaid