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General NPI Number Information
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NPI Number | 1356930820
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Entity Type | Organization
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Legal Business Name | STATE OF NEW YORK
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Dates
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Enumeration Date | 01/11/2021
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Last Update Date | 01/11/2021
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Provider Practice Location Address
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Address Line | 8045 WINCHESTER BLVD BLDG 8
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City | QUEENS VILLAGE
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State | NY
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Zip | 11427-2194
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Country | US
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Telephone | 718-217-5767
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Fax |
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Provider Business Mailing Address
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Address Line | 44 HOLLAND AVE
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City | ALBANY
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State | NY
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Zip | 12208-3411
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Country | US
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Telephone | 518-402-4333
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF CENTRAL OPERATIONS
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Name | EARL RAYMOND JEFFERSON
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Credential |
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Telephone | 518-402-4333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State |
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