Basic Information
| Provider Information | |||||||||
| NPI: | 1649468349 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF LEWIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | L.C. PUBLIC HEALTH-D&TC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7785 N STATE ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LOWVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133671229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153765453 | ||||||||
| FaxNumber: | 3153767013 | ||||||||
| Practice Location | |||||||||
| Address1: | 7785 N STATE ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LOWVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133671229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153765453 | ||||||||
| FaxNumber: | 3153767013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAITE | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PUBLIC HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 3153765453 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, BSN, MPH | ||||||||
| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 03936936 | 05 | NY | MEDICAID |