Provider Demographics
NPI:1235286394
Name:NYSARC INC COLUMBIA COUNTY CHAPTER
Entity Type:Organization
Organization Name:NYSARC INC COLUMBIA COUNTY CHAPTER
Other - Org Name:COARC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:STALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-672-4451
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:MELLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12544-0002
Mailing Address - Country:US
Mailing Address - Phone:518-672-4451
Mailing Address - Fax:518-672-0187
Practice Address - Street 1:2661 RAVISH RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-1026
Practice Address - Country:US
Practice Address - Phone:518-672-4451
Practice Address - Fax:518-672-0187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01012995Medicaid