Healthcare Provider Details

I. General information

NPI: 1104019991
Provider Name (Legal Business Name): MR. PHIL PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 SPRUCE STREET NORTH COLLINS
BUFFALO NY
14111
US

IV. Provider business mailing address

254 FRANKLIN ST LAKE SHORE BEHAVORIAL HEALTH
BUFFALO NY
14202-1954
US

V. Phone/Fax

Practice location:
  • Phone: 716-337-3706
  • Fax: 716-337-2723
Mailing address:
  • Phone: 716-842-0440
  • Fax: 716-842-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: