Provider Demographics
NPI:1023206646
Name:GUSTAVUS ADOLPHUS CHILD & FAMILY SERVICES
Entity type:Organization
Organization Name:GUSTAVUS ADOLPHUS CHILD & FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKWITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-665-8161
Mailing Address - Street 1:200 GUSTAVUS AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-1815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 FALCONER ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-1935
Practice Address - Country:US
Practice Address - Phone:716-665-2116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN SOCIAL SERVICES GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00356547Medicaid