Provider Demographics
NPI:1891729810
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:585-336-1400
Mailing Address - Street 1:800 CARTER STREET
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-339-4793
Mailing Address - Fax:585-336-4845
Practice Address - Street 1:3045 EAST AVENUE
Practice Address - Street 2:CENTRAL SQUARE HEALTH CENTER
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036
Practice Address - Country:US
Practice Address - Phone:315-676-2935
Practice Address - Fax:315-671-6976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355266Medicaid
NY00355266Medicaid