Provider Demographics
NPI:1790908812
Name:CLEM-MAR HOUSE, INC.
Entity Type:Organization
Organization Name:CLEM-MAR HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT PROJECT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWRY
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MS, CCMS, CCDP
Authorized Official - Phone:570-288-0403
Mailing Address - Street 1:PO BOX 2028
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-7038
Mailing Address - Country:US
Mailing Address - Phone:570-288-0403
Mailing Address - Fax:
Practice Address - Street 1:540 MAIN ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18704-2504
Practice Address - Country:US
Practice Address - Phone:570-288-0403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA407043324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016199680001Medicaid