Provider Demographics
NPI:1518721448
Name:TAVARES, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:TAVARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 MILL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LE RAYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18829-7780
Mailing Address - Country:US
Mailing Address - Phone:772-301-8828
Mailing Address - Fax:
Practice Address - Street 1:324 GOLDEN MILE RD
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-9230
Practice Address - Country:US
Practice Address - Phone:772-301-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty