Provider Demographics
NPI:1588094668
Name:THER CENTERS AT ST. CAMILLUS
Entity type:Organization
Organization Name:THER CENTERS AT ST. CAMILLUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ILST
Authorized Official - Prefix:
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:VENESE
Authorized Official - Last Name:ROSS-HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-703-0685
Mailing Address - Street 1:813 FAY RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-3009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:813 FAY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3009
Practice Address - Country:US
Practice Address - Phone:315-703-0685
Practice Address - Fax:315-488-3804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization