Provider Demographics
NPI:1316008311
Name:UPSTATE CEREBRAL PALSY, INC
Entity Type:Organization
Organization Name:UPSTATE CEREBRAL PALSY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GENO
Authorized Official - Middle Name:
Authorized Official - Last Name:DECONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-724-6907
Mailing Address - Street 1:125 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6305
Mailing Address - Country:US
Mailing Address - Phone:315-724-6907
Mailing Address - Fax:315-733-0791
Practice Address - Street 1:124 BROOKLEY ROAD
Practice Address - Street 2:CRP #7
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13441
Practice Address - Country:US
Practice Address - Phone:315-533-1166
Practice Address - Fax:315-533-1165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02708809315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02708809Medicaid