Provider Demographics
NPI:1639363153
Name:ORCHARD PARK CCRC, INC.
Entity Type:Organization
Organization Name:ORCHARD PARK CCRC, INC.
Other - Org Name:FOX RUN AT ORCHARD PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:WLODARCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:CHIEF FINANCIAL OFFI
Authorized Official - Phone:716-662-5001
Mailing Address - Street 1:ONE FOX RUN LANE
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-662-5001
Mailing Address - Fax:716-662-6985
Practice Address - Street 1:ONE FOX RUN LANE
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127
Practice Address - Country:US
Practice Address - Phone:716-662-5001
Practice Address - Fax:716-662-6985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02967540Medicaid
NY335854Medicare Oscar/Certification