Provider Demographics
NPI:1891845483
Name:FCCNYSARC
Entity Type:Organization
Organization Name:FCCNYSARC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-773-7931
Mailing Address - Street 1:465 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-1014
Mailing Address - Country:US
Mailing Address - Phone:518-773-7931
Mailing Address - Fax:518-725-2850
Practice Address - Street 1:465 N PERRY ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-1014
Practice Address - Country:US
Practice Address - Phone:518-773-7931
Practice Address - Fax:518-725-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00888528Medicaid