Provider Demographics
NPI:1558584458
Name:OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Other - Org Name:OAK ORCHARD HEALTH - ALBION
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:585-637-4220
Practice Address - Street 1:301 WEST AVE
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NY
Practice Address - Zip Code:14411
Practice Address - Country:US
Practice Address - Phone:585-589-5613
Practice Address - Fax:585-589-0872
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OAK ORCHARD COMMUNITY HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-10
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2701221R261QC1500X, 261QF0400X, 261QM1000X
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
NY5065333OtherBSWNY GRP #
NY331843Medicare ID - Type UnspecifiedFQHC ALBION #