Provider Demographics
NPI:1972828697
Name:CHILDRENS HM JEFFERSON CNTY B2H
Entity Type:Organization
Organization Name:CHILDRENS HM JEFFERSON CNTY B2H
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:PEG
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-788-7430
Mailing Address - Street 1:1704 STATE ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3102
Mailing Address - Country:US
Mailing Address - Phone:315-788-7430
Mailing Address - Fax:315-785-5637
Practice Address - Street 1:1704 STATE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3102
Practice Address - Country:US
Practice Address - Phone:315-788-7430
Practice Address - Fax:315-785-5637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00009545253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03137895Medicaid