Provider Demographics
NPI:1780746677
Name:LAFAVE, TARA L
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:L
Last Name:LAFAVE
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 1:20 TERREL WAY
Mailing Address - Street 2:
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-2435
Mailing Address - Country:US
Mailing Address - Phone:518-695-9438
Mailing Address - Fax:
Practice Address - Street 1:43 SPRING ST
Practice Address - Street 2:
Practice Address - City:SCHUYLERVILLE
Practice Address - State:NY
Practice Address - Zip Code:12871-1014
Practice Address - Country:US
Practice Address - Phone:518-695-3040
Practice Address - Fax:518-695-3150
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00006019156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5391060001OtherMEDICARE DME