Basic Information
Provider Information
NPI: 1700123825
EntityType: 2
ReplacementNPI:  
OrganizationName: SULLIVAN ARC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 162 E BROADWAY
Address2:  
City: MONTICELLO
State: NY
PostalCode: 127018815
CountryCode: US
TelephoneNumber: 8457961350
FaxNumber:  
Practice Location
Address1: 162 E BROADWAY
Address2:  
City: MONTICELLO
State: NY
PostalCode: 127018815
CountryCode: US
TelephoneNumber: 8457961350
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/09/2013
LastUpdateDate: 01/09/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SCHWARTZ
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName: RICHARD
AuthorizedOfficialTitleorPosition: DIRECTOR
AuthorizedOfficialTelephone: 8457961350
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251C00000X7393221NYY AgenciesDay Training, Developmentally Disabled Services 

No ID Information.


Home