Provider Demographics
NPI:1043498280
Name:CENTERVILLE CLINICS INC
Entity type:Organization
Organization Name:CENTERVILLE CLINICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NICCOLAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-632-6801
Mailing Address - Street 1:CENTERVILLE CLINICS INC
Mailing Address - Street 2:1070 OLD NATIONAL PIKE ROAD
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:CALIFORNIA MIDDLE SCHOOL
Practice Address - Street 2:40 TROJAN WAY
Practice Address - City:COAL CENTER
Practice Address - State:PA
Practice Address - Zip Code:15423-1059
Practice Address - Country:US
Practice Address - Phone:724-785-5800
Practice Address - Fax:724-785-8860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAAPPLYINGMedicaid
PA328864A859674OtherVALUE BEHAVIORAL HEALTH