Provider Demographics
NPI:1700202249
Name:CLINTON HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:CLINTON HOSPITAL CORPORATION
Other - Org Name:HAVEN CENTER FOR WOMEN'S HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:P
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3672
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:570-893-5043
Mailing Address - Fax:570-893-5126
Practice Address - Street 1:24 CREE DR
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-2639
Practice Address - Country:US
Practice Address - Phone:570-893-5043
Practice Address - Fax:570-893-5126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA122201261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007550910020Medicaid
PA393429Medicare Oscar/Certification