=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306103569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAYNE COUNTY DEPT OF AGING AND YOUTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2012
-----------------------------------------------------
Last Update Date | 04/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1519 NYE RD STE 300
-----------------------------------------------------
City | LYONS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14489-9115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-946-5624
-----------------------------------------------------
Fax | 315-946-5649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1519 NYE RD STE 300
-----------------------------------------------------
City | LYONS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14489-9115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-946-5624
-----------------------------------------------------
Fax | 315-946-5649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. PENNY W SHOCKLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-946-5624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------