Provider Demographics
NPI:1093701260
Name:EPISCOPAL CHURCH HOME & AFFILIATES LIFE CARE COMMUNITY, INC
Entity type:Organization
Organization Name:EPISCOPAL CHURCH HOME & AFFILIATES LIFE CARE COMMUNITY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-929-5801
Mailing Address - Street 1:705 RENAISSANCE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8052
Mailing Address - Country:US
Mailing Address - Phone:716-929-5800
Mailing Address - Fax:716-929-5812
Practice Address - Street 1:705 RENAISSANCE DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8052
Practice Address - Country:US
Practice Address - Phone:716-929-5800
Practice Address - Fax:716-929-5812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1421305N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000384000OtherBC/BS OF WNY
NY9UOtherINDEPENDENT HEALTH
NY0003009001OtherUNIVERA HEALTHCARE
NY02008395Medicaid
NY02008395Medicaid