Provider Demographics
NPI:1609122506
Name:PROJECT HOME
Entity type:Organization
Organization Name:PROJECT HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-320-6192
Mailing Address - Street 1:2144 CECIL B MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-4014
Mailing Address - Country:US
Mailing Address - Phone:215-320-6192
Mailing Address - Fax:484-229-3346
Practice Address - Street 1:2144 CECIL B MOORE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-4014
Practice Address - Country:US
Practice Address - Phone:215-320-6187
Practice Address - Fax:215-235-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-28
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101786047-0011Medicaid