Provider Demographics
NPI:1497758080
Name:HOSPICE OF ST LAWRENCE VALLEY INC
Entity Type:Organization
Organization Name:HOSPICE OF ST LAWRENCE VALLEY INC
Other - Org Name:HOSPICE AND PALLIATIVE CARE OF ST. LAWRENCE VALLEY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-265-3105
Mailing Address - Street 1:6805 US HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-3131
Mailing Address - Country:US
Mailing Address - Phone:315-265-3105
Mailing Address - Fax:315-265-0323
Practice Address - Street 1:6805 US HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-3131
Practice Address - Country:US
Practice Address - Phone:315-265-3105
Practice Address - Fax:315-265-0323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4429501F251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00977028Medicaid
NY00977028Medicaid