NPIMap

Organization Active NPI

Oak Orchard Community Health Center, Inc.

Doing business as Oak Orchard Health - Lyndonville

  • Federally Qualified Health Center (FQHC)
  • Lyndonville, NY
National Provider Identifier
1407189582
Registry record updated Jul 9, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Doing business as
Oak Orchard Health - Lyndonville
Practice address
77 S Main St
Lyndonville, NY 14098-9771
Phone
(585) 765-2060
Fax
(585) 765-2067
NPI assigned
Sep 8, 2009
Last updated
Jul 9, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
OAK ORCHARD COMMUNITY HEALTH CENTER, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 9, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Mary Ann Pettibon
Title
Ceo
Phone
(585) 637-3905

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X NU
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Migrant Health Clinic/Center 261QM1000X NU

Addresses

Primary practice location

77 S Main St
Lyndonville, NY 14098-9771

Mailing address

300 West Ave
Brockport, NY 14420-1118
Phone (585) 637-3905

Other identifiers 1

IdentifierTypeStateIssuer
00355308MedicaidNY

Other names 1

  • Oak Orchard Health - Lyndonville Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090916000658 NY Part A Provider - Federally Qualified Health Center (FQHC) 5496746927 Practice locations: Lyndonville, NY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407189582. Details of each certification follow.

Federally qualified health center certification: CCN 331008

Legal name
OAK ORCHARD COMMUNITY HEALTH CENTER, INC.
Doing business as
OAK ORCHARD HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 22, 2010
Last certification
Mar 22, 2010
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 21, 1973 in NY
Enrollment address
77 South Main Street
Lyndonville, NY 14098-9771

Other NPIs with the same Medicare PAC ID 10

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Oak Orchard Community Health Center Inc7 organizations share this tax ID, including this one
Part of
Oak Orchard Community Health Center Inc

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Lorienda Smith Individual Corporate DirectorBoard Member Dec 3, 2008
Karen Kinter Individual W-2 Managing EmployeeCeo Feb 22, 2023
George Sokolsky Individual Corporate DirectorBoard Member Mar 9, 2011
Karen Watt Individual Corporate DirectorBoard Member Sep 6, 2000
Randolph Dumas Individual Corporate Director Feb 17, 2021
Brandon Ball Individual Corporate Director Mar 22, 2023
Meredith Field Individual Corporate Director Aug 26, 2022
Renee Biedlingmaier Individual Corporate Director Jun 19, 2019
Nicole Morrissey Individual Corporate Director May 24, 2022
Emily Miller Individual Corporate OfficerCfo May 16, 2022
Leda Pacelli-Szabo Individual Corporate Director Jun 28, 2022
Nyla Gaylord Individual Corporate DirectorBoard Member Oct 10, 2018
Cynda Watroba Individual Corporate Director Jan 19, 2022

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Oak Orchard Community Health Center, Inc.Albion, NY, CCN 571832 Federally qualified health center Operational/Managerial Control Mar 9, 2022

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1252368000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1625788800000",
    "number": "1407189582",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 WEST AVE",
            "city": "BROCKPORT",
            "state": "NY",
            "postal_code": "144201118",
            "telephone_number": "585-637-3905",
            "fax_number": "585-637-4990"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "77 S MAIN ST",
            "city": "LYNDONVILLE",
            "state": "NY",
            "postal_code": "140989771",
            "telephone_number": "585-765-2060",
            "fax_number": "585-765-2067"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OAK ORCHARD COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "OAK ORCHARD COMMUNITY HEALTH CENTER, INC.",
        "enumeration_date": "2009-09-08",
        "last_updated": "2021-07-09",
        "certification_date": "2021-07-09",
        "status": "A",
        "authorized_official_last_name": "PETTIBON",
        "authorized_official_first_name": "MARY ANN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "585-637-3905",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QM1000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Migrant Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00355308",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Oak Orchard Health - Lyndonville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lyndonville, NY

Sources for this page

Verify at the official NPI Registry.