Provider Demographics
NPI:1386350346
Name:SARES, LANCE MIGUEL ARIS DEMAVIVAS (PT)
Entity type:Individual
Prefix:
First Name:LANCE MIGUEL ARIS
Middle Name:DEMAVIVAS
Last Name:SARES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1651
Mailing Address - Country:US
Mailing Address - Phone:315-787-4570
Mailing Address - Fax:315-787-4573
Practice Address - Street 1:196 NORTH ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1651
Practice Address - Country:US
Practice Address - Phone:315-787-4570
Practice Address - Fax:315-787-4573
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist