Provider Demographics
NPI:1750700399
Name:ANTHONY L. JORDAN HEALTH CORPORATION
Entity type:Organization
Organization Name:ANTHONY L. JORDAN HEALTH CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-423-2816
Mailing Address - Street 1:82 HOLLAND ST
Mailing Address - Street 2:ATTN: HR
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-2131
Mailing Address - Country:US
Mailing Address - Phone:585-423-2816
Mailing Address - Fax:
Practice Address - Street 1:950 NORTON ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3732
Practice Address - Country:US
Practice Address - Phone:585-324-3750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTHONY L. JORDAN HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-10
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2701211R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)