MEDICARE: MR. HERMAN AVILEZ MA (CSULA)

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency
2	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1306015912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HERMAN AVILEZ MA (CSULA)

Provider Business Mailing Address
First Line	:	2568 S MYRTLE AVE
Second Line	:
City	:	MONROVIA
State	:	CA
Zip	:	91016-5055
Country	:	US
Telephone Number	:	323-440-0733
Fax Number	:	323-722-4450

Provider Business Practice Location Address
First Line	:	3316 W BEVERLY BLVD
Second Line	:
City	:	MONTEBELLO
State	:	CA
Zip	:	90640-1537
Country	:	US
Telephone Number	:	323-722-4529
Fax Number	:	323-722-4450

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2008
Last Update Date	:	03/09/2017

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