Provider Demographics
NPI:1760576763
Name:COUNTY OF WAYNE
Entity Type:Organization
Organization Name:COUNTY OF WAYNE
Other - Org Name:WAYNE COUNTY PUBLIC HEALTH SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF PUBLIC HEALTH
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RN, ANP
Authorized Official - Phone:315-946-5749
Mailing Address - Street 1:1519 NYE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9133
Mailing Address - Country:US
Mailing Address - Phone:315-946-5749
Mailing Address - Fax:315-946-5762
Practice Address - Street 1:1519 NYE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9133
Practice Address - Country:US
Practice Address - Phone:315-946-5749
Practice Address - Fax:315-946-5762
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF WAYNE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5823200R251K00000X, 261Q00000X, 261QC1500X, 261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355413Medicaid
NY3001907Medicaid
NY337070Medicare Oscar/Certification