Provider Demographics
NPI:1699360974
Name:A-MAE-ZING DESIGN LLC
Entity Type:Organization
Organization Name:A-MAE-ZING DESIGN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GLENNA MAE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:BSN,RN
Authorized Official - Phone:585-797-4026
Mailing Address - Street 1:20 PHOENIX ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-2023
Mailing Address - Country:US
Mailing Address - Phone:585-797-4026
Mailing Address - Fax:
Practice Address - Street 1:20 PHOENIX ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-2023
Practice Address - Country:US
Practice Address - Phone:585-797-4026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1871188227Medicaid