1336339969 NPI number — CONIFER PARK, INC.

Table of content: (NPI 1336339969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336339969 NPI number — CONIFER PARK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONIFER PARK, 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:
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:
1336339969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10092
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12201-5092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-952-8408
Provider Business Mailing Address Fax Number:
518-399-6860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79 GLENRIDGE RD
Provider Second Line Business Practice Location Address:
COTTAGE #1
Provider Business Practice Location Address City Name:
GLENVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12302-4523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-952-8121
Provider Business Practice Location Address Fax Number:
518-952-8287
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OP BUSINESS MANAGER
Authorized Official Telephone Number:
518-952-8408

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  081110730 , 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: 01420800 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com