Provider Demographics
NPI:1962878074
Name:LEFAIVRE, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:LEFAIVRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CARRIAGE CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-3313
Mailing Address - Country:US
Mailing Address - Phone:248-247-4045
Mailing Address - Fax:
Practice Address - Street 1:140 CARRIAGE CIRCLE DR
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-3313
Practice Address - Country:US
Practice Address - Phone:248-247-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL116760603072172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI116760603072Medicaid