Basic Information
| Provider Information | |||||||||
| NPI: | 1669706628 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MBHW, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 LOHMAIER LN | ||||||||
| Address2: | |||||||||
| City: | LAKE KATRINE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124495245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453821200 | ||||||||
| FaxNumber: | 8453367510 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 STONE ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136013211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157827400 | ||||||||
| FaxNumber: | 3157827432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2009 | ||||||||
| LastUpdateDate: | 03/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | SAZER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8453821200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ESQ | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 7928002A | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.