Provider Demographics
NPI:1366175937
Name:220 FRONT STREET LLC
Entity type:Organization
Organization Name:220 FRONT STREET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:607-222-9913
Mailing Address - Street 1:220 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1514
Mailing Address - Country:US
Mailing Address - Phone:607-222-9913
Mailing Address - Fax:607-821-4855
Practice Address - Street 1:220 FRONT ST
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1514
Practice Address - Country:US
Practice Address - Phone:607-222-9913
Practice Address - Fax:607-821-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)