1538180856 NPI number — AVONELLE, INC

Table of content: (NPI 1538180856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538180856 NPI number — AVONELLE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVONELLE, 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:
6
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:
1538180856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8868 ROUTE 338
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOX
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8868 ROUTE 338
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOX
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-797-2828
Provider Business Practice Location Address Fax Number:
814-797-2870
Provider Enumeration Date:
07/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT, AVONELLE, INC.
Authorized Official Telephone Number:
814-226-4038

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PP411246L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3963940 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0012693960001 . This is a "PA PROMISE - MEDICAID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01269396 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".