Basic Information
Provider Information | |||||||||
NPI: | 1760747521 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE CHAUTAUQUA CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHAUTAUQUA CENTER, INC. | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 75 E 3RD ST | ||||||||
Address2: |   | ||||||||
City: | DUNKIRK | ||||||||
State: | NY | ||||||||
PostalCode: | 14048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7163636050 | ||||||||
FaxNumber: | 7163636333 | ||||||||
Practice Location | |||||||||
Address1: | 75 E 3RD ST | ||||||||
Address2: |   | ||||||||
City: | DUNKIRK | ||||||||
State: | NY | ||||||||
PostalCode: | 14048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7163636050 | ||||||||
FaxNumber: | 7163636333 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2012 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEASE | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7163636050 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 0376030 | 05 | NY |   | MEDICAID |