=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457857716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NYSARC, INC. CATTARAUGUS-NIAGARA COUNTY CHAPTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2018
-----------------------------------------------------
Last Update Date | 04/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6821 SAUNDERS SETTLEMENT RD
-----------------------------------------------------
City | SANBORN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14132-9440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-375-4747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1439 BUFFALO ST
-----------------------------------------------------
City | OLEAN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14760-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | BRENDA J THREEHOUSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-375-4747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------