Provider Demographics
NPI:1538370614
Name:NULTON DIAGNOSTIC AND TREATMENT CENTER
Entity type:Organization
Organization Name:NULTON DIAGNOSTIC AND TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:NULTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:814-262-0025
Mailing Address - Street 1:608 EAST PITT STREET
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16601
Mailing Address - Country:US
Mailing Address - Phone:814-624-3121
Mailing Address - Fax:
Practice Address - Street 1:608 EAST PITT STREET
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522
Practice Address - Country:US
Practice Address - Phone:814-624-3121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA312180, 312170251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007324900002Medicaid
PA1007324900016Medicaid