Provider Demographics
NPI:1235348244
Name:NORTH COUNTRY CTR FOR INDEPENDENCE
Entity Type:Organization
Organization Name:NORTH COUNTRY CTR FOR INDEPENDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:D
Authorized Official - Last Name:PULRANG
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:518-563-9058
Mailing Address - Street 1:102 SHARRON AVE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-3827
Mailing Address - Country:US
Mailing Address - Phone:518-563-9058
Mailing Address - Fax:518-563-0292
Practice Address - Street 1:102 SHARRON AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-3827
Practice Address - Country:US
Practice Address - Phone:518-563-9058
Practice Address - Fax:518-563-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01783866Medicaid