MEDICARE: KRISTEN TAVOULARIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	1202878	NY

General Provider Information

NPI Number	:	1972921245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN TAVOULARIS

Provider Business Mailing Address
First Line	:	36 EDGEWORTH ST
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-3219
Country	:	US
Telephone Number	:	516-295-2373
Fax Number	:

Provider Business Practice Location Address
First Line	:	36 EDGEWORTH ST
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-3219
Country	:	US
Telephone Number	:	516-295-2373
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2014
Last Update Date	:	04/02/2014

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