Provider Demographics
NPI:1811434103
Name:BETHANY VILLAGE PRIMARY CARE NETWORK, INC.
Entity type:Organization
Organization Name:BETHANY VILLAGE PRIMARY CARE NETWORK, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KISER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:607-378-6574
Mailing Address - Street 1:2977 WESTINGHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-8120
Mailing Address - Country:US
Mailing Address - Phone:607-378-6662
Mailing Address - Fax:607-378-6668
Practice Address - Street 1:2977 WESTINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8120
Practice Address - Country:US
Practice Address - Phone:607-378-6662
Practice Address - Fax:607-378-6668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care