Basic Information
Provider Information
NPI: 1134347230
EntityType: 2
ReplacementNPI:  
OrganizationName: KENDAL AT ITHACA
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 105 N SUNSET DR
Address2:  
City: ITHACA
State: NY
PostalCode: 148501459
CountryCode: US
TelephoneNumber: 6072725464
FaxNumber:  
Practice Location
Address1: 2230 N TRIPHAMMER RD
Address2:  
City: ITHACA
State: NY
PostalCode: 148506513
CountryCode: US
TelephoneNumber: 6072665300
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/23/2007
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: BUCKLIN
AuthorizedOfficialFirstName: RICHARD
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: HEALTH SERVICE ADMINISTRATOR
AuthorizedOfficialTelephone: 6072725300
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QP2000X01740-1NYY Ambulatory Health Care FacilitiesClinic/CenterPhysical Therapy

No ID Information.


Home