Provider Demographics
NPI:1053616102
Name:NYSARC, INC. FULTON COUNTY CHAPTER
Entity type:Organization
Organization Name:NYSARC, INC. FULTON COUNTY CHAPTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:KUZNIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-775-5412
Mailing Address - Street 1:127 E. STATE ST.
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078
Mailing Address - Country:US
Mailing Address - Phone:518-773-7931
Mailing Address - Fax:518-725-7617
Practice Address - Street 1:465 N. PERRY ST.
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095
Practice Address - Country:US
Practice Address - Phone:518-762-0024
Practice Address - Fax:518-762-3533
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NYSARC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-21
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10920252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01556321Medicaid
NYAA0485Medicare UPIN