Provider Demographics
NPI:1902926918
Name:WHITE DEER RUN, INC
Entity Type:Organization
Organization Name:WHITE DEER RUN, INC
Other - Org Name:WHITE DEER RUN OF WILLIAMSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-873-2131
Mailing Address - Street 1:901 WESTMINSTER DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-3909
Mailing Address - Country:US
Mailing Address - Phone:570-321-6127
Mailing Address - Fax:
Practice Address - Street 1:901 WESTMINSTER DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3909
Practice Address - Country:US
Practice Address - Phone:570-321-6127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE DEER RUN, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-31
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA417030251S00000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007567870050Medicaid