Provider Demographics
NPI:1467432765
Name:UNITED CEREBRAL PALSY ASSOCIATION OF THE NORTH COUNTRY, INC.
Entity Type:Organization
Organization Name:UNITED CEREBRAL PALSY ASSOCIATION OF THE NORTH COUNTRY, INC.
Other - Org Name:CEREBRAL PALSY OF THE NORTH COUNTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:TARIK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAATALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-386-1156
Mailing Address - Street 1:4 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3739
Mailing Address - Country:US
Mailing Address - Phone:315-386-1156
Mailing Address - Fax:315-379-9388
Practice Address - Street 1:4 COMMERCE LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3739
Practice Address - Country:US
Practice Address - Phone:315-386-1156
Practice Address - Fax:315-379-9388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
NY01995615Medicaid