Provider Demographics
NPI:1134771934
Name:WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Entity type:Organization
Organization Name:WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-253-8450
Mailing Address - Street 1:601 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:570-253-8226
Mailing Address - Fax:
Practice Address - Street 1:WAYMART PEDIATRIC CENTER
Practice Address - Street 2:27B WOODLANDS DR
Practice Address - City:WAYMART
Practice Address - State:PA
Practice Address - Zip Code:18472-9366
Practice Address - Country:US
Practice Address - Phone:570-488-9550
Practice Address - Fax:570-488-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty