Provider Demographics
NPI:1891933982
Name:ST. LAWRENCE NYSARC
Entity type:Organization
Organization Name:ST. LAWRENCE NYSARC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DAPHNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PICKERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-379-9531
Mailing Address - Street 1:6 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3738
Mailing Address - Country:US
Mailing Address - Phone:315-379-9531
Mailing Address - Fax:315-379-0834
Practice Address - Street 1:6 COMMERCE LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3738
Practice Address - Country:US
Practice Address - Phone:315-379-9531
Practice Address - Fax:315-379-0834
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NYSARC INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13327LA347B00000X
NY13328LA347B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347B00000XTransportation ServicesBus
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01449081Medicaid