Provider Demographics
NPI:1730274937
Name:DICK VAN DYKE ADDICTION TREATMENT CENTER
Entity type:Organization
Organization Name:DICK VAN DYKE ADDICTION TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE COMMISSIONER DIVISION OF
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-457-5312
Mailing Address - Street 1:1330 COUNTY ROAD 132
Mailing Address - Street 2:
Mailing Address - City:OVID
Mailing Address - State:NY
Mailing Address - Zip Code:14521
Mailing Address - Country:US
Mailing Address - Phone:607-869-9500
Mailing Address - Fax:607-869-5303
Practice Address - Street 1:1330 COUNTY ROAD 132
Practice Address - Street 2:
Practice Address - City:OVID
Practice Address - State:NY
Practice Address - Zip Code:14521
Practice Address - Country:US
Practice Address - Phone:607-869-9500
Practice Address - Fax:607-869-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health