1194722017 NPI number — ONTARIO COUNTY SUBSTANCE ABUSE

Table of content: (NPI 1194722017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194722017 NPI number — ONTARIO COUNTY SUBSTANCE ABUSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONTARIO COUNTY SUBSTANCE ABUSE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ONTARIO COUNTY SUBSTANCE ABUSE SERVICE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194722017
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3019 COUNTY COMPLEX DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANANDAIGUA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14424-9505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-396-4189
Provider Business Mailing Address Fax Number:
585-393-2916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3019 COUNTY COMPLEX DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANANDAIGUA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14424-9505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-396-4189
Provider Business Practice Location Address Fax Number:
585-393-2916
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FISHER
Authorized Official First Name:
JUNE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
585-396-4189

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01899687 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P0140037OC . This is a "BLUE CROSS AND BLUE SHIEL" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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