Provider Demographics
NPI:1386632628
Name:BRIODY HEALTH CARE FACILTIY LLC
Entity Type:Organization
Organization Name:BRIODY HEALTH CARE FACILTIY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:BRIODY
Authorized Official - Last Name:PETOCK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, LNH
Authorized Official - Phone:716-434-6361
Mailing Address - Street 1:909 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-6142
Mailing Address - Country:US
Mailing Address - Phone:716-434-6361
Mailing Address - Fax:716-434-6396
Practice Address - Street 1:909 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-6142
Practice Address - Country:US
Practice Address - Phone:716-434-6361
Practice Address - Fax:716-434-6396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3101300N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000626997001OtherBLUE CROSS
NY080047479OtherPALMETTO GBA
NYT5OtherINDEPENDENT HEALTH
NY000624931001OtherBLUE CROSS
NY000670038001OtherBLUE CROSS
NY000670088001OtherBLUE CROSS
NY000508042004OtherBLUE CROSS
NY0109980OtherINDEPENDENT HEALTH
NY000000219000OtherBLUE CROSS
NY00011419701OtherUNIVERA
NY00475443Medicaid
NY44OtherINDEPENDENT HEALTH
NY00010070502OtherUNIVERA
NY000624932001OtherBLUE CROSS
NY000626902001OtherBLUE CROSS
NY000640005006OtherBLUE CROSS
NY80084AOtherUPSTATE MEDICARE PART B
NY00010070502OtherUNIVERA