Healthcare Provider Details

I. General information

NPI: 1609928969
Provider Name (Legal Business Name): OTSELIC VALLEY CSD (GEORGETOWN-SOUTH OTSELIC CSD)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 COUNTY ROAD 13A
SOUTH OTSELIC NY
13155-0161
US

IV. Provider business mailing address

PO BOX 161 125 COUNTY ROAD 13A
SOUTH OTSELIC NY
13155-0161
US

V. Phone/Fax

Practice location:
  • Phone: 315-653-7218
  • Fax: 315-653-7500
Mailing address:
  • Phone: 315-653-7218
  • Fax: 315-653-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT GRANT BERSON
Title or Position: PRINCIPAL/BUSINESS ADMIN
Credential:
Phone: 315-653-7218