Provider Demographics
NPI:1619191855
Name:BAKER VICTORY HEALTHCARE CENTER
Entity Type:Organization
Organization Name:BAKER VICTORY HEALTHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCOFIDIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-828-9515
Mailing Address - Street 1:790 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-1696
Mailing Address - Country:US
Mailing Address - Phone:716-828-9350
Mailing Address - Fax:716-828-9355
Practice Address - Street 1:790 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-1696
Practice Address - Country:US
Practice Address - Phone:716-828-9350
Practice Address - Fax:716-828-9355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1402201R122300000X
NY122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01899518Medicaid