1225138548 NPI number — GENESEE VALLEY GROUP HEALTH ASSOCIATION

Table of content: (NPI 1225138548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225138548 NPI number — GENESEE VALLEY GROUP HEALTH ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESEE VALLEY GROUP HEALTH ASSOCIATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFETIME HEALTH MEDICAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225138548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 GARDENVILLE PKWY W
Provider Second Line Business Mailing Address:
PHARMACY
Provider Business Mailing Address City Name:
WEST SENECA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14224-1324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-656-4070
Provider Business Mailing Address Fax Number:
716-656-4330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 GARDENVILLE PKWY W
Provider Second Line Business Practice Location Address:
PHARMACY
Provider Business Practice Location Address City Name:
WEST SENECA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14224-1324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-656-4070
Provider Business Practice Location Address Fax Number:
716-656-4330
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AMBRES
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
716-857-6191

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X , with the licence number:  027322 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02618748 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027322 . This is a "NYS LICENSE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3366742 . This is a "NCPDP #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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