Healthcare Provider Details

I. General information

NPI: 1891835963
Provider Name (Legal Business Name): CEREBRAL PALSY & HANDICAPPED CHILDRENS ASSOC. OF CHEMUNG CO., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 OLD ITHACA RD ICF
HORSEHEADS NY
14845-7202
US

IV. Provider business mailing address

PO BOX 1554 1118 CHARLES ST
ELMIRA NY
14902-1554
US

V. Phone/Fax

Practice location:
  • Phone: 607-734-3592
  • Fax:
Mailing address:
  • Phone: 607-734-7107
  • Fax: 607-734-7334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number6515440
License Number StateNY

VIII. Authorized Official

Name: MARK PETERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 607-734-7107