Provider Demographics
NPI:1760648455
Name:SWEET FAMILY PRACTICE PC -FP PROGRAM
Entity Type:Organization
Organization Name:SWEET FAMILY PRACTICE PC -FP PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEET
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:570-268-6400
Mailing Address - Street 1:ROUTE 6 GOLDEN MILE
Mailing Address - Street 2:STE 341
Mailing Address - City:WYSOX
Mailing Address - State:PA
Mailing Address - Zip Code:18854-0341
Mailing Address - Country:US
Mailing Address - Phone:570-268-6400
Mailing Address - Fax:570-268-6401
Practice Address - Street 1:ROUTE 6 GOLDEN MILE
Practice Address - Street 2:STE 341
Practice Address - City:WYSOX
Practice Address - State:PA
Practice Address - Zip Code:18854-0341
Practice Address - Country:US
Practice Address - Phone:570-268-6400
Practice Address - Fax:570-268-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061835L261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014577730002Medicaid