Provider Demographics
NPI:1578869608
Name:ADIRONDACK PHYSICAL & OCCUPATIONAL THERAPY, LLC
Entity Type:Organization
Organization Name:ADIRONDACK PHYSICAL & OCCUPATIONAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-379-0992
Mailing Address - Street 1:19 HODSKIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1175
Mailing Address - Country:US
Mailing Address - Phone:315-379-0992
Mailing Address - Fax:315-379-0993
Practice Address - Street 1:127 E 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2104
Practice Address - Country:US
Practice Address - Phone:315-207-2222
Practice Address - Fax:315-343-6923
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADIRONDACK PHYSICAL & OCCUPATIONAL THERAPY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0113Medicare PIN