MEDICARE: MR. JAMES LAVALLE

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

General Provider Information

NPI Number	:	1083764369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES LAVALLE

Provider Business Mailing Address
First Line	:	2107 SPRUCE STREET
Second Line	:	NORTH COLLINS
City	:	NORTH COLLINS
State	:	NY
Zip	:	14111
Country	:	US
Telephone Number	:	716-337-3706
Fax Number	:	716-337-2723

Provider Business Practice Location Address
First Line	:	2107 SPRUCE STREET
Second Line	:	NORTH COLLINS
City	:	NORTH COLLINS
State	:	NY
Zip	:	14111
Country	:	US
Telephone Number	:	716-337-3706
Fax Number	:	716-337-2723

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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