Healthcare Provider Details

I. General information

NPI: 1609144021
Provider Name (Legal Business Name): GRANDMA'S WISH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 CLINTON ST
HOMER NY
13077-1047
US

IV. Provider business mailing address

63 CLINTON ST
HOMER NY
13077-1047
US

V. Phone/Fax

Practice location:
  • Phone: 607-345-6297
  • Fax:
Mailing address:
  • Phone: 607-345-6297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN M CHALTAIN
Title or Position: OWNER/PROGRAM COORDINATOR
Credential:
Phone: 607-345-6297