Healthcare Provider Details

I. General information

NPI: 1033266986
Provider Name (Legal Business Name): NORTHEASTERN CLINTON CENTRAL SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 STATE ROUTE 276
CHAMPLAIN NY
12919-4833
US

IV. Provider business mailing address

103 STATE ROUTE 276
CHAMPLAIN NY
12919-4833
US

V. Phone/Fax

Practice location:
  • Phone: 518-298-4031
  • Fax: 518-298-7892
Mailing address:
  • Phone: 518-298-4031
  • Fax: 518-298-7892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01403034
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: LISA L GRENVILLE
Title or Position: SUPERINTENDENT
Credential:
Phone: 518-298-8242