Provider Demographics
NPI:1740695568
Name:CREDO COMMUNITY CENTER FOR THE TREATMENT OF ADDICTIONS
Entity type:Organization
Organization Name:CREDO COMMUNITY CENTER FOR THE TREATMENT OF ADDICTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:SCORDO
Authorized Official - Suffix:
Authorized Official - Credentials:CASAC
Authorized Official - Phone:315-788-1530
Mailing Address - Street 1:595 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1335
Mailing Address - Country:US
Mailing Address - Phone:315-788-1530
Mailing Address - Fax:315-788-3794
Practice Address - Street 1:24180 COUNTY ROUTE 16
Practice Address - Street 2:
Practice Address - City:EVANS MILLS
Practice Address - State:NY
Practice Address - Zip Code:13637-3127
Practice Address - Country:US
Practice Address - Phone:315-788-1530
Practice Address - Fax:315-788-3794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141011632324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02996752Medicaid