Provider Demographics
NPI:1659427029
Name:EATING DISORDERS TREATMENT CENTER
Entity Type:Organization
Organization Name:EATING DISORDERS TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE LIAISON
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-810-0100
Mailing Address - Street 1:1200 BUSTLETON PIKE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4118
Mailing Address - Country:US
Mailing Address - Phone:215-364-7800
Mailing Address - Fax:
Practice Address - Street 1:1200 BUSTLETON PIKE
Practice Address - Street 2:SUITE 11
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-4118
Practice Address - Country:US
Practice Address - Phone:215-364-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA125680283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherTAX IDENTIFICATION NUMBER