Provider Demographics
NPI:1053617118
Name:WHITE DEER RUN LLC
Entity type:Organization
Organization Name:WHITE DEER RUN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP AND SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-861-6000
Mailing Address - Street 1:520 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6038
Mailing Address - Country:US
Mailing Address - Phone:570-322-4836
Mailing Address - Fax:570-322-4769
Practice Address - Street 1:520 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6038
Practice Address - Country:US
Practice Address - Phone:570-322-4836
Practice Address - Fax:570-322-4769
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE DEER RUN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-07
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA417040261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007567870061Medicaid
PA1007567870091Medicaid