Provider Demographics
NPI:1508051368
Name:PLACE OF REFUGE, INC
Entity Type:Organization
Organization Name:PLACE OF REFUGE, INC
Other - Org Name:THE PLACE OF REFUGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-909-8550
Mailing Address - Street 1:2938 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-2801
Mailing Address - Country:US
Mailing Address - Phone:267-909-8550
Mailing Address - Fax:267-909-8552
Practice Address - Street 1:2938 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-2801
Practice Address - Country:US
Practice Address - Phone:267-909-8550
Practice Address - Fax:267-909-8552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAIN PROCESS251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022577860001Medicaid