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Organization

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Active
Organization subpart
No

Provider details

NPI number
Authorized official
MATTHEW DWYER (DIRECTOR OF REVENUE MANAGEMENT)
(518) 781-4567
Entity
Organization

Contact information

Practice address
13640 RTE 22, CANAAN, NY 12029
(518) 781-4567
(518) 781-4566
Mailing address
13640 RTE 22, CANAAN, NY 12029
(518) 781-4567
(518) 781-4566

Taxonomy

Speciality
Code
Description
License number
State
251V00000X
Voluntary or Charitable Agency
Primary
051010545
NY

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
00327899
NY
Enumeration date
04/02/2007
Last updated
12/09/2025
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