Provider Demographics
NPI:1053560623
Name:CCP
Entity type:Organization
Organization Name:CCP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:724-337-3591
Mailing Address - Street 1:410 9TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-6406
Mailing Address - Country:US
Mailing Address - Phone:724-337-3591
Mailing Address - Fax:724-337-3592
Practice Address - Street 1:410 9TH ST
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-6406
Practice Address - Country:US
Practice Address - Phone:724-337-3591
Practice Address - Fax:724-337-3592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAP-N093516-L313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility