Basic Information
| Provider Information | |||||||||
| NPI: | 1821688276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONVERSE | ||||||||
| FirstName: | VICTORIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4077 LAKES CORNERS ROSE VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144339628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153983743 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 590 FISHERS STATION DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | VICTOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145649744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859247207 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2021 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.