Healthcare Provider Details

I. General information

NPI: 1679702955
Provider Name (Legal Business Name): STATE OF NEW YORK COMPTROLLERS OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 CAMP HILL RD
COPAKE NY
12516-1400
US

IV. Provider business mailing address

44 HOLLAND AVE
ALBANY NY
12229-0001
US

V. Phone/Fax

Practice location:
  • Phone: 518-329-4851
  • Fax:
Mailing address:
  • Phone: 518-402-4333
  • Fax: 518-473-1874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number00275410
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name: EARL JEFFERSON
Title or Position: DIRECTOR OF CENTRAL OPERATIONS
Credential:
Phone: 510-402-4333