MEDICARE: DICK VAN DYKE ADDICTION TREATMENT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency		NY

General Provider Information

NPI Number	:	1730274937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DICK VAN DYKE ADDICTION TREATMENT CENTER

Provider Business Mailing Address
First Line	:	1330 COUNTY ROAD 132
Second Line	:
City	:	OVID
State	:	NY
Zip	:	14521
Country	:	US
Telephone Number	:	607-869-9500
Fax Number	:	607-869-5303

Provider Business Practice Location Address
First Line	:	1330 COUNTY ROAD 132
Second Line	:
City	:	OVID
State	:	NY
Zip	:	14521
Country	:	US
Telephone Number	:	607-869-9500
Fax Number	:	607-869-5303

Authorized Official
Title or Position	:	ASSOCIATE COMMISSIONER DIVISION OF
Name	:	MR. MICHAEL A LAWLER
Credential	:
Telephone Number	:	518-457-5312

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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