Provider Demographics
NPI:1740688423
Name:KIDSPEACE CHILDREN'S HOSPITAL, INC.
Entity type:Organization
Organization Name:KIDSPEACE CHILDREN'S HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-799-8525
Mailing Address - Street 1:KIDSPEACE CORPORATION
Mailing Address - Street 2:4085 INDEPENDENCE DR
Mailing Address - City:SCHNECKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18078
Mailing Address - Country:US
Mailing Address - Phone:610-799-8525
Mailing Address - Fax:610-799-8318
Practice Address - Street 1:451 W. CHEW ST.
Practice Address - Street 2:SUITE 105
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102
Practice Address - Country:US
Practice Address - Phone:610-776-5465
Practice Address - Fax:610-663-3270
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDSPEACE CHILDREN'S HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-12
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA218750261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007283700027Medicaid
PA100728370-0016Medicaid