Healthcare Provider Details

I. General information

NPI: 1902564800
Provider Name (Legal Business Name): DANIEL WALTER LAVIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 DOG RIVER DRIVE
NORTHFIELD VT
05663
US

IV. Provider business mailing address

85 EDGEBROOK RD
FRAMINGHAM MA
01701-3813
US

V. Phone/Fax

Practice location:
  • Phone: 802-485-8550
  • Fax:
Mailing address:
  • Phone: 508-788-5567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number105501
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: