Provider Demographics
NPI:1710213236
Name:CD EAST FAMILY HEALTH & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CD EAST FAMILY HEALTH & WELLNESS CENTER LLC
Other - Org Name:CD EAST FAMILY HEALTH & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY-BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-695-3704
Mailing Address - Street 1:845 SIR THOMAS CT
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4840
Mailing Address - Country:US
Mailing Address - Phone:717-695-3704
Mailing Address - Fax:717-695-7735
Practice Address - Street 1:845 SIR THOMAS CT
Practice Address - Street 2:SUITE 5
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4840
Practice Address - Country:US
Practice Address - Phone:717-695-3704
Practice Address - Fax:717-695-7735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD418042261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1942306162OtherOWNER PERSONAL NPI
PA01784747Medicaid
PAH72041Medicare UPIN