Healthcare Provider Details

I. General information

NPI: 1073701579
Provider Name (Legal Business Name): TABASCO FAMILY PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GOLDEN LN
KERHONKSON NY
12446-1609
US

IV. Provider business mailing address

5 GOLDEN LN
KERHONKSON NY
12446-1609
US

V. Phone/Fax

Practice location:
  • Phone: 845-626-3424
  • Fax: 845-626-4627
Mailing address:
  • Phone: 845-626-3424
  • Fax: 845-626-4627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number188450
License Number StateNY

VIII. Authorized Official

Name: DR. LUCINDA GROVENBURG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 845-626-3424