Provider Demographics
NPI:1811417827
Name:ESSEX COUNTY CHAPTER NYSARC, INC
Entity Type:Organization
Organization Name:ESSEX COUNTY CHAPTER NYSARC, INC
Other - Org Name:MOUNTAIN LAKE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEPHEW
Authorized Official - Suffix:
Authorized Official - Credentials:EXECUTIVE DIRECTOR
Authorized Official - Phone:518-546-3381
Mailing Address - Street 1:10 ST PATRICK PL
Mailing Address - Street 2:
Mailing Address - City:PORT HENRY
Mailing Address - State:NY
Mailing Address - Zip Code:12974-1200
Mailing Address - Country:US
Mailing Address - Phone:518-546-3381
Mailing Address - Fax:518-546-7138
Practice Address - Street 1:10 ST PATRICK PL
Practice Address - Street 2:
Practice Address - City:PORT HENRY
Practice Address - State:NY
Practice Address - Zip Code:12974-1200
Practice Address - Country:US
Practice Address - Phone:518-546-3381
Practice Address - Fax:518-546-7138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY15090188021252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01276842Medicaid