Basic Information
| Provider Information | |||||||||
| NPI: | 1598751547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST CATHERINE LABOURE MEDICAL ADULT DAY HEALTHCARE PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2157 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142142648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168621450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2157 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142142648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168621450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 03/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | DUNLOP | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 7168622431 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST CATHERINE LABOURE HEALTH CARE CENTER | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | 01743920 | 05 | NY | MEDICAID |