Provider Demographics
NPI:1932271251
Name:CENTRAL NEW YORK DC, LLC
Entity Type:Organization
Organization Name:CENTRAL NEW YORK DC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-785-7521
Mailing Address - Street 1:2100 CENTRAL AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2838
Mailing Address - Country:US
Mailing Address - Phone:303-785-7523
Mailing Address - Fax:
Practice Address - Street 1:910 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1060
Practice Address - Country:US
Practice Address - Phone:315-410-8040
Practice Address - Fax:315-410-8030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3301217R261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY97005OtherMVP PROVIDER NUMBER
NY02300801Medicaid
NY332615Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER