Provider Demographics
NPI:1790333292
Name:SUSQUEHANNA COMMUNITY HEALTH AND DENTAL CLINIC, INC
Entity Type:Organization
Organization Name:SUSQUEHANNA COMMUNITY HEALTH AND DENTAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSEKNECHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MBA
Authorized Official - Phone:570-567-5418
Mailing Address - Street 1:471 HEPBURN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6122
Mailing Address - Country:US
Mailing Address - Phone:570-567-5400
Mailing Address - Fax:
Practice Address - Street 1:431 HEPBURN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6122
Practice Address - Country:US
Practice Address - Phone:570-567-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)