Provider Demographics
NPI:1538294699
Name:NORTH COUNTRY TRANSITIONAL LIVING SERVICES, INC
Entity Type:Organization
Organization Name:NORTH COUNTRY TRANSITIONAL LIVING SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-782-1777
Mailing Address - Street 1:482 CITY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2365
Mailing Address - Country:US
Mailing Address - Phone:315-782-1777
Mailing Address - Fax:315-785-8628
Practice Address - Street 1:482 CITY CENTER DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2365
Practice Address - Country:US
Practice Address - Phone:315-782-1777
Practice Address - Fax:315-785-8628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02135582Medicaid
NY01305022Medicaid