Basic Information
Provider Information
NPI: 1922197516
EntityType: 2
ReplacementNPI:  
OrganizationName: LUZERNE IU
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 368 TIOGA AVE
Address2:  
City: KINGSTON
State: PA
PostalCode: 187045117
CountryCode: US
TelephoneNumber: 5702879681
FaxNumber: 5702875721
Practice Location
Address1: 368 TIOGA AVE
Address2:  
City: KINGSTON
State: PA
PostalCode: 187045117
CountryCode: US
TelephoneNumber: 5702879681
FaxNumber: 5702875721
Other Information
ProviderEnumerationDate: 10/12/2006
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: OSTROWSKI
AuthorizedOfficialFirstName: MICHAEL
AuthorizedOfficialMiddleName: M
AuthorizedOfficialTitleorPosition: EXECUTIVE DIRECTOR
AuthorizedOfficialTelephone: 5707628884
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251300000X PAY AgenciesLocal Education Agency (LEA) 

ID Information
IDTypeStateIssuerDescription
100003669000205PA MEDICAID


Home