Healthcare Provider Details

I. General information

NPI: 1447398201
Provider Name (Legal Business Name): SYLVAN LIEBLA AMERICAN LEGION POST 1363
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 05/11/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 COLLINS ROAD
ELDRED NY
12732
US

IV. Provider business mailing address

PO BOX 16996
ROCHESTER NY
14616-0996
US

V. Phone/Fax

Practice location:
  • Phone: 845-557-8915
  • Fax: 845-557-8915
Mailing address:
  • Phone: 585-563-1112
  • Fax: 585-434-3312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number5212
License Number StateNY

VIII. Authorized Official

Name: MR. LOUIS PINE
Title or Position: SECRETARY, TREASURER, CAPTAIN
Credential: EMT
Phone: 845-557-6989