Healthcare Provider Details

I. General information

NPI: 1083764369
Provider Name (Legal Business Name): MR. JAMES LAVALLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 SPRUCE STREET NORTH COLLINS
NORTH COLLINS NY
14111
US

IV. Provider business mailing address

2107 SPRUCE STREET NORTH COLLINS
NORTH COLLINS NY
14111
US

V. Phone/Fax

Practice location:
  • Phone: 716-337-3706
  • Fax: 716-337-2723
Mailing address:
  • Phone: 716-337-3706
  • Fax: 716-337-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: