Basic Information
| Provider Information | |||||||||
| NPI: | 1184897258 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE SHORE BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 254 FRANKLIN STREET | ||||||||
| Address2: | LAKE SHORE BEHAVIORAL HEALTH | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 NIAGARA STREET | ||||||||
| Address2: | TRANSPORTATION | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168562587 | ||||||||
| FaxNumber: | 7168562608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 04/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | HITZEL | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7168420440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 347C00000X | Y | Transportation Services | Private Vehicle |
No ID Information.