Provider Demographics
NPI:1225138548
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:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBRES
Authorized Official - Suffix:
Authorized Official - Credentials:MD,MS
Authorized Official - Phone:716-857-6191
Mailing Address - Street 1:120 GARDENVILLE PKWY W
Mailing Address - Street 2:PHARMACY
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1324
Mailing Address - Country:US
Mailing Address - Phone:716-656-4070
Mailing Address - Fax:716-656-4330
Practice Address - Street 1:120 GARDENVILLE PKWY W
Practice Address - Street 2:PHARMACY
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1324
Practice Address - Country:US
Practice Address - Phone:716-656-4070
Practice Address - Fax:716-656-4330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0273223336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02618748Medicaid
NY027322OtherNYS LICENSE #
NY3366742OtherNCPDP #
NY3366742OtherNCPDP #