Provider Demographics
NPI:1740645324
Name:OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Entity type:Organization
Organization Name:OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:585-637-4990
Practice Address - Street 1:7309 SENECA RD N STE 112
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-9691
Practice Address - Country:US
Practice Address - Phone:607-324-0314
Practice Address - Fax:607-324-0318
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-23
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2701221R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)