Provider Demographics
NPI:1548262363
Name:ITHACA ALPHA HOUSE CENTER, INC.
Entity type:Organization
Organization Name:ITHACA ALPHA HOUSE CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICERE
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:OAKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-387-5535
Mailing Address - Street 1:38 EAST MAIN STREET
Mailing Address - Street 2:PO BOX 724
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886
Mailing Address - Country:US
Mailing Address - Phone:607-387-5535
Mailing Address - Fax:607-387-5526
Practice Address - Street 1:334 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5432
Practice Address - Country:US
Practice Address - Phone:607-273-5500
Practice Address - Fax:607-273-1277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ITHACA ALPHA HOUSE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-11
Last Update Date:2016-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070510837261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01292828Medicaid
NY01292828Medicaid