Basic Information
| Provider Information | |||||||||
| NPI: | 1285840074 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN TIER INDEPENDENCE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 E FREDERICK ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139041224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077242111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 135 E FREDERICK ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139041224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077242111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | WATSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6077242111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251E00000X | N | Agencies | Home Health | 251X00000X | N | Agencies | Supports Brokerage | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 02516310 | 05 | NY | MEDICAID | 02003001 | 05 | NY | MEDICAID | 01543122 | 05 | NY | MEDICAID | 02693649 | 05 | NY | MEDICAID | 01741166 | 05 | NY | MEDICAID | 02168761 | 05 | NY | MEDICAID | 02625478 | 05 | NY | MEDICAID | 01489734 | 05 | NY | MEDICAID |