Provider Demographics
NPI:1578961298
Name:CHAUTUAQUA COUNTY OFFICE FOR THE AGING
Entity Type:Organization
Organization Name:CHAUTUAQUA COUNTY OFFICE FOR THE AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR ACCOUNT CLERK
Authorized Official - Prefix:MS
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:D
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-753-4473
Mailing Address - Street 1:7 N ERIE ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1027
Mailing Address - Country:US
Mailing Address - Phone:716-753-4471
Mailing Address - Fax:716-753-4477
Practice Address - Street 1:7 N ERIE ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:14757-1027
Practice Address - Country:US
Practice Address - Phone:716-753-4471
Practice Address - Fax:716-753-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01997144Medicaid