Healthcare Provider Details

I. General information

NPI: 1194380964
Provider Name (Legal Business Name): CHENANGO VALLEY ADULT ENRICHMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 CANASAWACTA ST
NORWICH NY
13815-1623
US

IV. Provider business mailing address

24 CANASAWACTA ST
NORWICH NY
13815-1623
US

V. Phone/Fax

Practice location:
  • Phone: 607-334-6598
  • Fax: 607-336-6625
Mailing address:
  • Phone: 607-334-6598
  • Fax: 607-336-6625

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: MRS. JENNIFER VICTORIA-MAE RANDALL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 607-334-6598