Provider Demographics
NPI:1992002505
Name:120 RIDER AVENUE OPERATING COMPANY, LP
Entity Type:Organization
Organization Name:120 RIDER AVENUE OPERATING COMPANY, LP
Other - Org Name:PEDIATRIC SPECIALTY CARE AT LANCASTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-236-8712
Mailing Address - Street 1:590 MADISON AVE
Mailing Address - Street 2:21ST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2524
Mailing Address - Country:US
Mailing Address - Phone:212-810-1503
Mailing Address - Fax:
Practice Address - Street 1:120 RIDER AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-4831
Practice Address - Country:US
Practice Address - Phone:717-394-0882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA328590251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA328590OtherPENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE
PA328690OtherPENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE