Healthcare Provider Details

I. General information

NPI: 1285774885
Provider Name (Legal Business Name): LORD ADMOZ CASAC - T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 INDUCON DR E
SANBORN NY
14132-9014
US

IV. Provider business mailing address

38 OAKGROVE AVE
BUFFALO NY
14208-1006
US

V. Phone/Fax

Practice location:
  • Phone: 716-731-2030
  • Fax: 716-731-3010
Mailing address:
  • Phone: 716-885-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number20688
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: