Basic Information
| Provider Information | |||||||||
| NPI: | 1790326320 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACCESS: SUPPORTS FOR LIVING INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 FORTUNE RD W | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109411625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456924454 | ||||||||
| FaxNumber: | 8456928887 | ||||||||
| Practice Location | |||||||||
| Address1: | 16 UNION ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109404906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456924454 | ||||||||
| FaxNumber: | 8456928887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2019 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | COLAVITO | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8456924454 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 00275085 | 05 | NY | MEDICAID |