Provider Demographics
NPI:1306103569
Name:WAYNE COUNTY DEPT OF AGING AND YOUTH
Entity type:Organization
Organization Name:WAYNE COUNTY DEPT OF AGING AND YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-946-5624
Mailing Address - Street 1:1519 NYE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9115
Mailing Address - Country:US
Mailing Address - Phone:315-946-5624
Mailing Address - Fax:315-946-5649
Practice Address - Street 1:1519 NYE RD STE 300
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9115
Practice Address - Country:US
Practice Address - Phone:315-946-5624
Practice Address - Fax:315-946-5649
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01295514Medicaid