Provider Demographics
NPI:1962491852
Name:NYSARC, INC. BROOME-TIOGA COUNTY CHAPTER
Entity Type:Organization
Organization Name:NYSARC, INC. BROOME-TIOGA COUNTY CHAPTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:THORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-723-8361
Mailing Address - Street 1:125 CUTLER POND RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1564
Mailing Address - Country:US
Mailing Address - Phone:607-723-8361
Mailing Address - Fax:607-231-5310
Practice Address - Street 1:125 CUTLER POND RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1564
Practice Address - Country:US
Practice Address - Phone:607-723-8361
Practice Address - Fax:607-231-5310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6066441320600000X
NY6066443320600000X
NY6066440320600000X
NY6066454320600000X
NY6066442320600000X
NY6066450320600000X
NY6066461320600000X
NY6066462320600000X
NY6066120320600000X
NY6066444320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02246082Medicaid