Healthcare Provider Details

I. General information

NPI: 1942326020
Provider Name (Legal Business Name): AVALON BIOTECHNICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3364 KAY RD
LAKESIDE AZ
85929-5405
US

IV. Provider business mailing address

PO BOX 1912
SHOW LOW AZ
85902-1912
US

V. Phone/Fax

Practice location:
  • Phone: 928-368-8200
  • Fax: 928-368-8208
Mailing address:
  • Phone: 928-368-8200
  • Fax: 928-368-8208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number15235
License Number StateAZ

VIII. Authorized Official

Name: DR. MARC A BAUDER
Title or Position: OWNER
Credential: MD
Phone: 928-368-8200