Provider Demographics
NPI:1922156314
Name:KENSINGTON HOSPITAL OUTPATIENT TREATMENT PROGRAM
Entity Type:Organization
Organization Name:KENSINGTON HOSPITAL OUTPATIENT TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:215-426-8100
Mailing Address - Street 1:136 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122-1721
Mailing Address - Country:US
Mailing Address - Phone:215-426-8100
Mailing Address - Fax:215-965-2344
Practice Address - Street 1:136 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-1721
Practice Address - Country:US
Practice Address - Phone:215-426-8100
Practice Address - Fax:215-965-2344
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENSINGTON HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA807340261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007717290013Medicaid