Healthcare Provider Details

I. General information

NPI: 1225298623
Provider Name (Legal Business Name): DBA SULLIVAN ARC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 E BROADWAY
MONTICELLO NY
12701-8815
US

IV. Provider business mailing address

162 E BROADWAY
MONTICELLO NY
12701-8815
US

V. Phone/Fax

Practice location:
  • Phone: 845-796-1350
  • Fax: 845-796-1647
Mailing address:
  • Phone: 845-796-1350
  • Fax: 845-796-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number002976-1
License Number StateNY

VIII. Authorized Official

Name: JOHN J SCHWARTZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 845-796-1350