1205831955 NPI number — AVELLA OF GILBERT, INC.

Table of content: (NPI 1205831955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205831955 NPI number — AVELLA OF GILBERT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVELLA OF GILBERT, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205831955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1606 W WHISPERING WIND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85085-0678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-434-1700
Provider Business Mailing Address Fax Number:
623-434-3673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2450 E GUADALUPE RD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85234-5116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-633-6934
Provider Business Practice Location Address Fax Number:
480-633-6974
Provider Enumeration Date:
06/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MUSIL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
623-434-3657

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  Y005083 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 698318 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0326721 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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