Provider Demographics
NPI:1174741821
Name:GAUDENZIA INC
Entity type:Organization
Organization Name:GAUDENZIA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR. FISCAL & ACCOUNTING OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:610-239-9600
Mailing Address - Street 1:106 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401-4716
Mailing Address - Country:US
Mailing Address - Phone:610-239-9600
Mailing Address - Fax:610-275-7025
Practice Address - Street 1:1300 SPRING GARDEN STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123
Practice Address - Country:US
Practice Address - Phone:215-440-9669
Practice Address - Fax:215-440-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA176280261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1002285890091Medicaid
PA1002285890029Medicaid