# FAYETTE COUNTY MENTAL HEALTH MENTAL RETARDATION PROGRAM

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1639202534
- **Authorized official:** MR. DAVID RIDER M.A., M.DIV. (ADMINISTRATOR CEO)
- **Authorized official phone:** (724) 430-1370

## Contact information

- **Practice address:** 215 JACOB MURPHY LN, UNIONTOWN, PA 15401-2777
- **Practice address phone:** (724) 430-1370
- **Practice address fax:** (724) 430-1386
- **Mailing address:** 215 JACOB MURPHY LN, UNIONTOWN, PA 15401-2777
- **Mailing address phone:** (724) 430-1370
- **Mailing address fax:** (724) 430-1386

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 171M00000X | Case Manager/Care Coordinator | — | NULL | Yes |
| 171M00000X | Case Manager/Care Coordinator | — | — | Yes |
| 251B00000X | Case Management Agency | — | NULL | — |
| 302R00000X | Health Maintenance Organization | — | NULL | — |

## Other

- **Enumeration date:** 03/13/2007
- **Last updated:** 01/03/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0017040300001 | — | PA |
| 05 | — | 1007538290003 | — | PA |
| 05 | — | 1007538290004 | — | PA |
| 05 | — | 1007538290005 | — | PA |