Provider Demographics
NPI:1558882720
Name:WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Other - Org Name:HONESDALE BEHAVORIAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-253-8450
Mailing Address - Street 1:601 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MAPLE AVE STE 15
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1460
Practice Address - Country:US
Practice Address - Phone:570-253-8219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty