Provider Demographics
NPI:1689008468
Name:ST. LAWRENCE COUNTY COMMUNITY DEVELOPMENT PROGRAM
Entity Type:Organization
Organization Name:ST. LAWRENCE COUNTY COMMUNITY DEVELOPMENT PROGRAM
Other - Org Name:CDP
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-386-1102
Mailing Address - Street 1:1 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-9676
Mailing Address - Country:US
Mailing Address - Phone:315-386-1102
Mailing Address - Fax:315-386-1454
Practice Address - Street 1:1 COMMERCE LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-9676
Practice Address - Country:US
Practice Address - Phone:315-386-1102
Practice Address - Fax:315-386-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7008L002251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00953902Medicaid