Provider Demographics
NPI:1720260904
Name:JENNY ROSE SPECIALIZED THERAPY CENTER LLC
Entity Type:Organization
Organization Name:JENNY ROSE SPECIALIZED THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:CHT
Authorized Official - Phone:570-421-3415
Mailing Address - Street 1:296 E BROWN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3011
Mailing Address - Country:US
Mailing Address - Phone:570-421-3415
Mailing Address - Fax:570-421-9873
Practice Address - Street 1:296 E BROWN ST
Practice Address - Street 2:SUITE B
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3011
Practice Address - Country:US
Practice Address - Phone:570-421-3415
Practice Address - Fax:570-421-9873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005819213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018703100005Medicaid
PA1018703100004Medicaid