Provider Demographics
NPI:1710790639
Name:ANGELS LIGHT HALFWAY HOUSE DERRY LLC
Entity type:Organization
Organization Name:ANGELS LIGHT HALFWAY HOUSE DERRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMASIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-846-5644
Mailing Address - Street 1:201 DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:15697-1617
Mailing Address - Country:US
Mailing Address - Phone:267-846-6564
Mailing Address - Fax:
Practice Address - Street 1:314 PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:NEW DERRY
Practice Address - State:PA
Practice Address - Zip Code:15671-1033
Practice Address - Country:US
Practice Address - Phone:267-846-6564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility