1710371539 NPI number — 73 NORTH OF GRANVILLE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710371539 NPI number — 73 NORTH OF GRANVILLE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
73 NORTH OF GRANVILLE, 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:
Provider Other Organization Name Type Code:
6
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:
1710371539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
73 NORTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12832-1136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-642-3476
Provider Business Mailing Address Fax Number:
518-642-3801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
73 NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12832-1136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-642-3476
Provider Business Practice Location Address Fax Number:
518-642-3801
Provider Enumeration Date:
03/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PAUQUETTE
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
HOLLISTER
Authorized Official Title or Position:
ADMINISTRATOR/ OWNER
Authorized Official Telephone Number:
518-642-3476

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  760-F-014 , 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)





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