Provider Demographics
NPI:1740437136
Name:BERKSHIRE FARM CENTER & SEVICES FOR YOUTH
Entity type:Organization
Organization Name:BERKSHIRE FARM CENTER & SEVICES FOR YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIACCHETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-781-4567
Mailing Address - Street 1:13640 STATE ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:NY
Mailing Address - Zip Code:12029
Mailing Address - Country:US
Mailing Address - Phone:518-781-4567
Mailing Address - Fax:518-781-0505
Practice Address - Street 1:3464 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-515-7972
Practice Address - Fax:718-515-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051010545251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02497758Medicaid