Provider Demographics
NPI:1184027955
Name:NORTHERN REGIONAL CENTER FOR INDEPENDENT LIVING
Entity Type:Organization
Organization Name:NORTHERN REGIONAL CENTER FOR INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-785-8703
Mailing Address - Street 1:210 COURT ST STE 107
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4547
Mailing Address - Country:US
Mailing Address - Phone:315-785-8703
Mailing Address - Fax:315-785-8612
Practice Address - Street 1:210 COURT ST STE 107
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4547
Practice Address - Country:US
Practice Address - Phone:315-785-8703
Practice Address - Fax:315-785-8612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management