Basic Information
| Provider Information | |||||||||
| NPI: | 1952893091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JERICHO ROAD MINISTRIES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JERICHO ROAD COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 184 BARTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142131573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168816191 | ||||||||
| FaxNumber: | 7168816247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142121460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165293020 | ||||||||
| FaxNumber: | 7165293040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ENDRESS | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7163483000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JERICHO ROAD MINISTRIES, INC. | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 1401237R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.