Basic Information
| Provider Information | |||||||||
| NPI: | 1326245747 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAVALLEE | ||||||||
| FirstName: | ROLAND | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 HUNTERS RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031105014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034724424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 140 QUEEN CITY AVE | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031037122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036269500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 05/21/2019 | ||||||||
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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 | 207QA0401X | 8396 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207Q00000X | NH 8396 | NH | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30003649 | 05 | NH | MEDICAID |