Provider Demographics
NPI:1457067001
Name:UPSTATE CENTER FOR MARTIAL ARTS LLC
Entity Type:Organization
Organization Name:UPSTATE CENTER FOR MARTIAL ARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-728-1672
Mailing Address - Street 1:1930 OSTERLITZ AVE
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12306-4922
Mailing Address - Country:US
Mailing Address - Phone:518-888-5603
Mailing Address - Fax:
Practice Address - Street 1:1524 CENTRAL AVE STE 210
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5065
Practice Address - Country:US
Practice Address - Phone:518-478-6437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty