Provider Demographics
NPI:1508819087
Name:MONROE WHEELCHAIR OF THE SOUTHERN TIER REGION
Entity Type:Organization
Organization Name:MONROE WHEELCHAIR OF THE SOUTHERN TIER REGION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTERDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-385-3920
Mailing Address - Street 1:3340 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-4612
Mailing Address - Country:US
Mailing Address - Phone:585-385-3920
Mailing Address - Fax:585-385-6966
Practice Address - Street 1:217 MAIN ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2627
Practice Address - Country:US
Practice Address - Phone:607-729-8244
Practice Address - Fax:607-729-8248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02441587Medicaid
NY02441587Medicaid