Provider Demographics
NPI:1700408390
Name:KETTLE CREEK OUTFITTERS LTD
Entity type:Organization
Organization Name:KETTLE CREEK OUTFITTERS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:FLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-502-2919
Mailing Address - Street 1:88 QUIET OAKS CAMPGROUND LN
Mailing Address - Street 2:
Mailing Address - City:CROSS FORK
Mailing Address - State:PA
Mailing Address - Zip Code:17729-9430
Mailing Address - Country:US
Mailing Address - Phone:570-502-2919
Mailing Address - Fax:570-923-1799
Practice Address - Street 1:88 QUIET OAKS CAMPGROUND LN
Practice Address - Street 2:
Practice Address - City:CROSS FORK
Practice Address - State:PA
Practice Address - Zip Code:17729-9430
Practice Address - Country:US
Practice Address - Phone:570-502-2919
Practice Address - Fax:570-923-1799
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETTLE CREEK OUTFITTERS LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare