Healthcare Provider Details

I. General information

NPI: 1730721093
Provider Name (Legal Business Name): MS. BEVERLY LYNN AVIANI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 AVILA BEACH DR
SAN LUIS OBISPO CA
93405-8046
US

IV. Provider business mailing address

275 SAN LUIS AVE
PISMO BEACH CA
93449-2219
US

V. Phone/Fax

Practice location:
  • Phone: 805-704-1999
  • Fax:
Mailing address:
  • Phone: 805-704-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: