Healthcare Provider Details

I. General information

NPI: 1679618227
Provider Name (Legal Business Name): JENNIFER DIANNE LIVI PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10714 NORTH RD
PERRYSBURG NY
14129-9746
US

IV. Provider business mailing address

123 TREMONT AVE
KENMORE NY
14217-2333
US

V. Phone/Fax

Practice location:
  • Phone: 716-672-3400
  • Fax: 716-672-3409
Mailing address:
  • Phone: 716-523-1567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0059801
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: