Healthcare Provider Details

I. General information

NPI: 1124659057
Provider Name (Legal Business Name): ANTHONY AVALOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 TECHNOLOGY CT STE 105
RIVERSIDE CA
92507-2155
US

IV. Provider business mailing address

4545 MEREDITH ST
RIVERSIDE CA
92505-1536
US

V. Phone/Fax

Practice location:
  • Phone: 951-285-2650
  • Fax:
Mailing address:
  • Phone: 951-415-3263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: