Basic Information
| Provider Information | |||||||||
| NPI: | 1508926528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPSTATE CEREBRAL PALSY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 MARY ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135011930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157246907 | ||||||||
| FaxNumber: | 3157220971 | ||||||||
| Practice Location | |||||||||
| Address1: | 1247 TILDEN AVE | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135014100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157381734 | ||||||||
| FaxNumber: | 3157333869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | DECONDO | ||||||||
| AuthorizedOfficialFirstName: | GENO | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3157246907 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 01346607 | NY | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 01346607 | 05 | NY | MEDICAID |