Healthcare Provider Details

I. General information

NPI: 1457067001
Provider Name (Legal Business Name): UPSTATE CENTER FOR MARTIAL ARTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 CENTRAL AVE STE 210
ALBANY NY
12205-5065
US

IV. Provider business mailing address

1930 OSTERLITZ AVE
SCHENECTADY NY
12306-4922
US

V. Phone/Fax

Practice location:
  • Phone: 518-478-6437
  • Fax:
Mailing address:
  • Phone: 518-888-5603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: GEORGE BROWN
Title or Position: OWNER
Credential:
Phone: 518-728-1672