Healthcare Provider Details

I. General information

NPI: 1538082821
Provider Name (Legal Business Name): BAKER VICTORY HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 RIDGE RD FL 1
LACKAWANNA NY
14218-1629
US

IV. Provider business mailing address

790 RIDGE RD
LACKAWANNA NY
14218-1629
US

V. Phone/Fax

Practice location:
  • Phone: 716-893-7337
  • Fax:
Mailing address:
  • Phone: 716-343-5566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY DESTRO
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 716-343-5566