Provider Demographics
NPI:1376790766
Name:BERKSHIRE FARM CENTER & SERVICES FOR YOUTH
Entity Type:Organization
Organization Name:BERKSHIRE FARM CENTER & SERVICES FOR YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIACCHETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-781-4567
Mailing Address - Street 1:13640 STATE ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:NY
Mailing Address - Zip Code:12029-3504
Mailing Address - Country:US
Mailing Address - Phone:518-781-4567
Mailing Address - Fax:518-781-0505
Practice Address - Street 1:1059 SIBLEY TOWER BLDG
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604
Practice Address - Country:US
Practice Address - Phone:585-454-1620
Practice Address - Fax:585-454-6814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05101054251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02825845Medicaid