Basic Information
| Provider Information | |||||||||
| NPI: | 1417101114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAVINE | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1824 MOUNTAINSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234346752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575823930 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 917 BEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH DAYTONA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321191712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867564395 | ||||||||
| FaxNumber: | 8664262811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2008 | ||||||||
| LastUpdateDate: | 11/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OP006634 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.