Healthcare Provider Details

I. General information

NPI: 1174515712
Provider Name (Legal Business Name): CENTRAL NEW YORK PET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W TAFT RD SUITE 2C
LIVERPOOL NY
13088-3807
US

IV. Provider business mailing address

4567 CROSSROADS PARK DR 2ND FLOOR
LIVERPOOL NY
13088-3589
US

V. Phone/Fax

Practice location:
  • Phone: 315-452-2666
  • Fax: 315-452-2669
Mailing address:
  • Phone: 315-295-2100
  • Fax: 315-295-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number108725
License Number StateNY

VIII. Authorized Official

Name: DR. ALAN B FOSTER
Title or Position: DIRECTOR OF OPERATIONS
Credential: M.D.
Phone: 315-452-2555