Provider Demographics
NPI:1841721644
Name:TACONIC INNOVATIONS
Entity type:Organization
Organization Name:TACONIC INNOVATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATHIAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:ONI-ESELEH
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:845-296-1042
Mailing Address - Street 1:872 ROUTE 376
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-6464
Mailing Address - Country:US
Mailing Address - Phone:845-296-1042
Mailing Address - Fax:845-296-0801
Practice Address - Street 1:872 ROUTE 376
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-6464
Practice Address - Country:US
Practice Address - Phone:845-296-1042
Practice Address - Fax:845-296-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302R00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No302R00000XManaged Care OrganizationsHealth Maintenance Organization