=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215091152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANFORTH ADULT CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 DANFORTH ST
-----------------------------------------------------
City | HOOSICK FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12090-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-686-5167
-----------------------------------------------------
Fax | 518-686-4428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 COMPUTER DR E
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12205-1276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-459-0786
-----------------------------------------------------
Fax | 518-459-0775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GLENN MAZULA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-459-0786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 0815L001
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------