Provider Demographics
NPI:1003447012
Name:STATE OF NEW YORK
Entity Type:Organization
Organization Name:STATE OF NEW YORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CENTRAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-402-4333
Mailing Address - Street 1:44 HOLLAND AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3411
Mailing Address - Country:US
Mailing Address - Phone:518-402-4333
Mailing Address - Fax:
Practice Address - Street 1:8045 WINCHESTER BLVD BLDG 08
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2194
Practice Address - Country:US
Practice Address - Phone:718-217-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW YORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities