Provider Demographics
NPI:1174649925
Name:GENESEE VALLEY GROUP HEALTH ASSOCIATION
Entity Type:Organization
Organization Name:GENESEE VALLEY GROUP HEALTH ASSOCIATION
Other - Org Name:LIFETIME HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT REGIONAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-338-1400
Mailing Address - Street 1:130 EMPIRE DR
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1320
Mailing Address - Country:US
Mailing Address - Phone:716-668-6170
Mailing Address - Fax:
Practice Address - Street 1:130 EMPIRE DR
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1320
Practice Address - Country:US
Practice Address - Phone:716-668-6170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00011283019OtherGROUP# BEH HEALTH PHD