Basic Information
| Provider Information | |||||||||
| NPI: | 1356493894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROTCHED MOUNTAIN COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 VERNEY DR | ||||||||
| Address2: | CROTCHED MOUNTAIN FOUNDATION | ||||||||
| City: | GREENFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030475000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035473311 | ||||||||
| FaxNumber: | 6035473232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1873 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122035028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184521214 | ||||||||
| FaxNumber: | 5184523546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHUMWAY | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6035473311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | NY | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 01739380 | 05 | NY | MEDICAID |