Basic Information
Provider Information | |||||||||
NPI: | 1376673202 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PENN FOUNDATION, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENN FOUNDATION, INC. INTELLECTUAL DISABILITIES SUPPORTS COORDINATION | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 807 LAWN AVE | ||||||||
Address2: | P.O. BOX 32 | ||||||||
City: | SELLERSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 189601549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2152576551 | ||||||||
FaxNumber: | 2152579347 | ||||||||
Practice Location | |||||||||
Address1: | 64 N COUNTY LINE RD | ||||||||
Address2: |   | ||||||||
City: | SOUDERTON | ||||||||
State: | PA | ||||||||
PostalCode: | 189641159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2152571183 | ||||||||
FaxNumber: | 2152570485 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2007 | ||||||||
LastUpdateDate: | 07/20/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MUGRAUER | ||||||||
AuthorizedOfficialFirstName: | WAYNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2152576551 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.P.A. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | Y |   | Agencies | Case Management |   |
No ID Information.