Basic Information
| Provider Information | |||||||||
| NPI: | 1659798734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF VETERAN AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2098 ALBANY POST RD | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105481454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147374400 | ||||||||
| FaxNumber: | 9147884362 | ||||||||
| Practice Location | |||||||||
| Address1: | 2098 ALBANY POST RD | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105481454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147374400 | ||||||||
| FaxNumber: | 9147884362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | LATANYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCE SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9147374400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | HRMS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 086090 | NY | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.