Provider Demographics
NPI:1447390760
Name:CEREBRAL PALSY & HANDICAPPED CHILDRENS ASSOCIATION OF CHEMUNG CO., INC
Entity Type:Organization
Organization Name:CEREBRAL PALSY & HANDICAPPED CHILDRENS ASSOCIATION OF CHEMUNG CO., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-734-7107
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:1118 CHARLES ST
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14902-1554
Mailing Address - Country:US
Mailing Address - Phone:607-734-7107
Mailing Address - Fax:607-734-7334
Practice Address - Street 1:398 OLD ITHACA RD
Practice Address - Street 2:DAY TREATMENT
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-7202
Practice Address - Country:US
Practice Address - Phone:607-739-3592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6515300261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00806762Medicaid