1548262363 NPI number — ITHACA ALPHA HOUSE CENTER, INC.

Table of content: (NPI 1548262363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548262363 NPI number — ITHACA ALPHA HOUSE CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ITHACA ALPHA HOUSE CENTER, INC.
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:
CAYUGA ADDICTION RECOVERY SERVICES OUTPATIENT PROGRAM
Provider Other Organization Name Type Code:
3
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:
1548262363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 EAST MAIN STREET
Provider Second Line Business Mailing Address:
PO BOX 724
Provider Business Mailing Address City Name:
TRUMANSBURG
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14886
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-387-5535
Provider Business Mailing Address Fax Number:
607-387-5526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
334 W STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850-5432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-273-5500
Provider Business Practice Location Address Fax Number:
607-273-1277
Provider Enumeration Date:
08/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OAKS
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICERE
Authorized Official Telephone Number:
607-387-5535

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  070510837 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01292828 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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