Provider Demographics
NPI:1215621586
Name:UPSTATE PCA INSTITUTE
Entity type:Organization
Organization Name:UPSTATE PCA INSTITUTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:HHA,PCA
Authorized Official - Phone:315-864-0416
Mailing Address - Street 1:1216 GRAY AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-3967
Mailing Address - Country:US
Mailing Address - Phone:315-864-0416
Mailing Address - Fax:270-203-0587
Practice Address - Street 1:1216 GRAY AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3959
Practice Address - Country:US
Practice Address - Phone:315-542-4209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-08
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No251E00000XAgenciesHome Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty