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General NPI Number Information
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NPI Number | 1780922302
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Entity Type | Organization
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Legal Business Name | RIVERFRONT MEDICAL
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Dates
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Enumeration Date | 01/17/2013
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Last Update Date | 01/17/2013
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Provider Practice Location Address
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Address Line | 105 WOODBERRY LN
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City | FAYETTEVILLE
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State | NY
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Zip | 13066-1745
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Country | US
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Telephone | 315-445-9655
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Fax |
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Provider Business Mailing Address
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Address Line | 1020 7TH NORTH ST SUITE 220
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City | LIVERPOOL
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State | NY
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Zip | 13088-6192
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Country | US
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Telephone | 315-451-3906
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PETER CLARK
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Credential |
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Telephone | 315-451-3906
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1800X
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Taxonomy Name | Corporate Health Clinic/Center
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License Number | 163502-1
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License Number State | NY
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