Provider Demographics
NPI:1043519986
Name:JEFFERSON REHABILITATION CENTER
Entity type:Organization
Organization Name:JEFFERSON REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-788-2730
Mailing Address - Street 1:420 GAFFNEY DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 GAFFNEY DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1823
Practice Address - Country:US
Practice Address - Phone:315-788-2730
Practice Address - Fax:315-788-8557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016569-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency