Provider Demographics
NPI:1649391319
Name:WHITE DEER RUN, LLC
Entity Type:Organization
Organization Name:WHITE DEER RUN, LLC
Other - Org Name:WHITE DEER RUN AT BLUE MOUNTAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT AND SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-861-6000
Mailing Address - Street 1:PO BOX 199
Mailing Address - Street 2:
Mailing Address - City:KEMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:19529-0199
Mailing Address - Country:US
Mailing Address - Phone:610-756-4023
Mailing Address - Fax:
Practice Address - Street 1:8284 LEASER ROAD
Practice Address - Street 2:
Practice Address - City:KEMPTON
Practice Address - State:PA
Practice Address - Zip Code:19529
Practice Address - Country:US
Practice Address - Phone:610-756-4023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA397052101YA0400X
PASS1960505251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007567870068Medicaid