Organization
KENCCID
Active
Other names
KenCCID
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL ANTHONY DEANGELO (IT SYSTEMS DIRECTOR)
(215) 288-9797
Entity
Organization
Contact information
Practice address
9350 ASHTON RD RM 202, PHILADELPHIA, PA 19114-7402
(215) 288-9797
Mailing address
9350 ASHTON RD RM 202, PHILADELPHIA, PA 19114-7402
(215) 288-9797
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100001000
—
PA
Enumeration date
10/22/2020
Last updated
10/22/2020
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