Provider Demographics
NPI:1043397490
Name:NYSARC INC. ONONDAGA COUNTY CHAPTER
Entity Type:Organization
Organization Name:NYSARC INC. ONONDAGA COUNTY CHAPTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUITIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STANFORT
Authorized Official - Middle Name:J
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-476-7441
Mailing Address - Street 1:600 S WILBUR AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2730
Mailing Address - Country:US
Mailing Address - Phone:315-476-7441
Mailing Address - Fax:315-424-6001
Practice Address - Street 1:600 S WILBUR AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2730
Practice Address - Country:US
Practice Address - Phone:315-476-7441
Practice Address - Fax:315-424-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00560238Medicaid
NY01474799Medicaid
NY01162096Medicaid
NY01162096Medicaid