1396733762 NPI number — COXSACKIE RESCUE SQUAD

Table of content: (NPI 1396733762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396733762 NPI number — COXSACKIE RESCUE SQUAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COXSACKIE RESCUE SQUAD
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:
1396733762
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:
PO BOX 290184
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WETHERSFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06129-0184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-452-8191
Provider Business Mailing Address Fax Number:
860-721-6362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 MANSION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COXSACKIE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12051-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-731-9444
Provider Business Practice Location Address Fax Number:
518-731-2620
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LIZOTTE
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
M
Authorized Official Title or Position:
AUTHORIZED AGENT
Authorized Official Telephone Number:
800-452-8191

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  1915 , 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: 01423977 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com