Provider Demographics
NPI:1245634286
Name:VAILLANCOURT, GENEVIEVE R (LAC)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:R
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:GENEVIEVE
Other - Middle Name:R
Other - Last Name:VALENTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:443 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-2124
Mailing Address - Country:US
Mailing Address - Phone:207-558-1131
Mailing Address - Fax:
Practice Address - Street 1:443 MAIN ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-2124
Practice Address - Country:US
Practice Address - Phone:207-558-1131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC507171100000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1598482226OtherNPI