Healthcare Provider Details

I. General information

NPI: 1295309466
Provider Name (Legal Business Name): WESTERN NEW YORK MEDICAL PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4384 LAKEVILLE RD
GENESEO NY
14454-9761
US

IV. Provider business mailing address

4384 LAKEVILLE RD
GENESEO NY
14454-9761
US

V. Phone/Fax

Practice location:
  • Phone: 585-243-2020
  • Fax:
Mailing address:
  • Phone: 585-243-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE S HOLDER
Title or Position: DIRECTOR, PAYER ENROLLMENT
Credential:
Phone: 585-922-0293