Provider Demographics
NPI:1972645893
Name:CORNELL ABRAXAS GROUP LLC
Entity Type:Organization
Organization Name:CORNELL ABRAXAS GROUP LLC
Other - Org Name:CORNELL ABRAXAS I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SADLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-566-6656
Mailing Address - Street 1:2840 LIBERTY AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15222-4776
Mailing Address - Country:US
Mailing Address - Phone:814-566-6656
Mailing Address - Fax:814-927-8560
Practice Address - Street 1:165 ABRAXAS ROAD
Practice Address - Street 2:
Practice Address - City:MARIENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16239
Practice Address - Country:US
Practice Address - Phone:814-566-6656
Practice Address - Fax:814-927-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2710103245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA271010OtherDDAPL LICENSE