| NPI | 1518768068 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARY LOU STAIB Provider Enrollment Specialist 518-697-3258 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QR1300X Clinic/Center, Rural Health |
| Enumeration Date | 2025-03-21 |
| Last Update Date | 2025-03-21 |