Provider Demographics
NPI:1770285769
Name:LAKE SCRANTON RENEW CENTER
Entity type:Organization
Organization Name:LAKE SCRANTON RENEW CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALCHUNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-800-5926
Mailing Address - Street 1:1141 MOOSIC ST STE 3
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2105
Mailing Address - Country:US
Mailing Address - Phone:570-800-5926
Mailing Address - Fax:570-955-5556
Practice Address - Street 1:1141 MOOSIC ST STE 3
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2105
Practice Address - Country:US
Practice Address - Phone:570-800-5926
Practice Address - Fax:570-955-5556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE SCRANTON URGENT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-21
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty