Healthcare Provider Details

I. General information

NPI: 1306015912
Provider Name (Legal Business Name): HERMAN AVILEZ MA (CSULA)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: HERMAN AVILEZ CERTIFICATION DRUG

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 W BEVERLY BLVD
MONTEBELLO CA
90640-1537
US

IV. Provider business mailing address

2568 S MYRTLE AVE
MONROVIA CA
91016-5055
US

V. Phone/Fax

Practice location:
  • Phone: 323-722-4529
  • Fax: 323-722-4450
Mailing address:
  • Phone: 323-440-0733
  • Fax: 323-722-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: