Provider Demographics
NPI:1750104386
Name:TAVAREZ, RAYMOND (REPAIR TECHNICIAN)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:TAVAREZ
Suffix:
Gender:M
Credentials:REPAIR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2221
Mailing Address - Country:US
Mailing Address - Phone:631-704-6212
Mailing Address - Fax:
Practice Address - Street 1:18 EVERETT ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2221
Practice Address - Country:US
Practice Address - Phone:631-704-6212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor