Healthcare Provider Details

I. General information

NPI: 1518574060
Provider Name (Legal Business Name): WESTERN NEW YORK INTEGRATED CARE COLLABORATIVE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 DELAWARE AVE
BUFFALO NY
14209-2202
US

IV. Provider business mailing address

742 DELAWARE AVE
BUFFALO NY
14209-2202
US

V. Phone/Fax

Practice location:
  • Phone: 716-431-5100
  • Fax:
Mailing address:
  • Phone: 716-431-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: NICOLE KMICINSKI
Title or Position: EXECUTIVE DIRECTOR
Credential: RD
Phone: 716-431-5100