Provider Demographics
NPI:1134381353
Name:SELF-DIRECT, INC.
Entity type:Organization
Organization Name:SELF-DIRECT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALUMBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-635-5374
Mailing Address - Street 1:7758 MAPLE ROAD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027
Mailing Address - Country:US
Mailing Address - Phone:315-635-5374
Mailing Address - Fax:315-635-5375
Practice Address - Street 1:7758 MAPLE ROAD
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027
Practice Address - Country:US
Practice Address - Phone:315-635-5374
Practice Address - Fax:315-635-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-29
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1606L001251E00000X
NY5386080002332B00000X
333300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333300000XSuppliersEmergency Response System Companies
No251E00000XAgenciesHome Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02413674Medicaid
NY02473792Medicaid
NY02413674Medicaid