Provider Demographics
NPI:1568121655
Name:LIFE MALE SCIENCE TECHNOLOGY ENGINEERING ARTS AND MATH ACADEMY
Entity Type:Organization
Organization Name:LIFE MALE SCIENCE TECHNOLOGY ENGINEERING ARTS AND MATH ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:CANADY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:252-266-1111
Mailing Address - Street 1:11888 PALOMINO CT
Mailing Address - Street 2:
Mailing Address - City:NORTH HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:15642-6712
Mailing Address - Country:US
Mailing Address - Phone:252-266-1111
Mailing Address - Fax:
Practice Address - Street 1:777 PENN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PENN HILLS
Practice Address - State:PA
Practice Address - Zip Code:15235-5927
Practice Address - Country:US
Practice Address - Phone:412-745-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-15
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchoolGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1750548665Medicaid
PA1912070988Medicaid