Provider Demographics
NPI:1427382738
Name:THE M.O.G.
Entity Type:Organization
Organization Name:THE M.O.G.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:CERTO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:716-773-1600
Mailing Address - Street 1:1801 GRAND ISLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2171
Mailing Address - Country:US
Mailing Address - Phone:716-773-1600
Mailing Address - Fax:716-773-9418
Practice Address - Street 1:1801 GRAND ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-2171
Practice Address - Country:US
Practice Address - Phone:716-773-1600
Practice Address - Fax:716-773-9418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175L00000XOther Service ProvidersHomeopathGroup - Single Specialty