Provider Demographics
NPI:1407189582
Name:OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Other - Org Name:OAK ORCHARD HEALTH - LYNDONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIBON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-637-3905
Mailing Address - Street 1:300 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1118
Mailing Address - Country:US
Mailing Address - Phone:585-637-3905
Mailing Address - Fax:585-637-4990
Practice Address - Street 1:77 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:NY
Practice Address - Zip Code:14098-9771
Practice Address - Country:US
Practice Address - Phone:585-765-2060
Practice Address - Fax:585-765-2067
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-08
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM1000XAmbulatory Health Care FacilitiesClinic/CenterMigrant Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355308Medicaid