Provider Demographics
NPI:1700384807
Name:CENTERVILLE CLINICS INC
Entity Type:Organization
Organization Name:CENTERVILLE CLINICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICCOLAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-632-6801
Mailing Address - Street 1:1070 OLD NATIONAL PIKE ROAD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:801 EAST WHEELING ST.
Practice Address - Street 2:WASHINGTON PARK ELEMENTARY
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301
Practice Address - Country:US
Practice Address - Phone:724-223-5150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007288440027Medicaid