Basic Information
| Provider Information | |||||||||
| NPI: | 1760755201 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENN FOUNDATION, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | COMMUNITY RESIDENTIAL SERVICES-ADULT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 LAWN AVE | ||||||||
| Address2: | |||||||||
| City: | SELLERSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189601549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152576551 | ||||||||
| FaxNumber: | 2152579347 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 LOUX LN | ||||||||
| Address2: | |||||||||
| City: | SELLERSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189602804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152570527 | ||||||||
| FaxNumber: | 2675170024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2012 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MUGRAUER | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2152576551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.P.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.