Basic Information
| Provider Information | |||||||||
| NPI: | 1376890798 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERIE COUNTY SOUTHEAST CORP V | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SPECTRUM HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | BOX 631 | ||||||||
| Address2: | 227 THORN AVENUE | ||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166622040 | ||||||||
| FaxNumber: | 7166620019 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142021309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166622040 | ||||||||
| FaxNumber: | 7166620019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2012 | ||||||||
| LastUpdateDate: | 07/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | NISBET | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT./CEO | ||||||||
| AuthorizedOfficialTelephone: | 7166622040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.