1639215064 NPI number — NORTHERN NEW YORK CEREBRAL PALSY ASSOCIATION

Table of content: (NPI 1639215064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639215064 NPI number — NORTHERN NEW YORK CEREBRAL PALSY ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN NEW YORK CEREBRAL PALSY ASSOCIATION
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:
1639215064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13601-4032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-788-5650
Provider Business Mailing Address Fax Number:
315-788-9186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601-4032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-788-5650
Provider Business Practice Location Address Fax Number:
315-788-9186
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRABANT
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
315-788-5650

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01026273 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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