Provider Demographics
NPI:1194857292
Name:ODD FELLOW AND REBEKAH REHABILITATION AND HEALTH CARE CENTER
Entity Type:Organization
Organization Name:ODD FELLOW AND REBEKAH REHABILITATION AND HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:DICARLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-434-6324
Mailing Address - Street 1:104 OLD NIAGARA RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-1500
Mailing Address - Country:US
Mailing Address - Phone:716-434-6324
Mailing Address - Fax:716-434-4020
Practice Address - Street 1:104 OLD NIAGARA RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-1500
Practice Address - Country:US
Practice Address - Phone:716-434-6324
Practice Address - Fax:716-434-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3101305N314000000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00356372Medicaid
NY00356372Medicaid