Healthcare Provider Details

I. General information

NPI: 1124455894
Provider Name (Legal Business Name): LORI URBANCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 SAINT JOHNS PARKSIDE ST
BUFFALO NY
14210-2515
US

IV. Provider business mailing address

45 OAKWOOD DR
CHEEKTOWAGA NY
14227-3219
US

V. Phone/Fax

Practice location:
  • Phone: 716-828-9560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1912958
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: