Provider Demographics
NPI:1609122506
Name:PROJECT HOME
Entity Type:Organization
Organization Name:PROJECT HOME
Other - Org Name:STEPHEN KLEIN WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:SPECIAL PROJECTS COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-203-1367
Mailing Address - Street 1:2144 CECIL B MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-4014
Mailing Address - Country:US
Mailing Address - Phone:215-320-6187
Mailing Address - Fax:215-235-4441
Practice Address - Street 1:2144 CECIL B MOORE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-4014
Practice Address - Country:US
Practice Address - Phone:215-320-6187
Practice Address - Fax:215-235-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-28
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101786047-0011Medicaid