Provider Demographics
NPI:1710319082
Name:MARANATHA FAMILY CENTER, LLC
Entity Type:Organization
Organization Name:MARANATHA FAMILY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:518-234-2868
Mailing Address - Street 1:1461 STATE ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:RICHMONDVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12149-2305
Mailing Address - Country:US
Mailing Address - Phone:518-234-2868
Mailing Address - Fax:518-254-7050
Practice Address - Street 1:1461 STATE ROUTE 7
Practice Address - Street 2:
Practice Address - City:RICHMONDVILLE
Practice Address - State:NY
Practice Address - Zip Code:12149-2305
Practice Address - Country:US
Practice Address - Phone:518-234-2868
Practice Address - Fax:518-254-7050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006533-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01358983Medicaid
53993BMedicare PIN
NY01358983Medicaid