Provider Demographics
NPI:1740339829
Name:1003 WALNUT ST INC
Entity type:Organization
Organization Name:1003 WALNUT ST INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-732-5646
Mailing Address - Street 1:1003 WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901
Mailing Address - Country:US
Mailing Address - Phone:607-732-5646
Mailing Address - Fax:607-732-0373
Practice Address - Street 1:1003 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901
Practice Address - Country:US
Practice Address - Phone:607-732-5646
Practice Address - Fax:607-732-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY78100018A283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital