Healthcare Provider Details

I. General information

NPI: 1275988040
Provider Name (Legal Business Name): AVANTI SPORTS MEDICINE & FITNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 N REDWOOD DR SUITE 275
SAN RAFAEL CA
94903-1972
US

IV. Provider business mailing address

219 BRANNAN ST SUITE A
SAN FRANCISCO CA
94107-4030
US

V. Phone/Fax

Practice location:
  • Phone: 800-704-0028
  • Fax:
Mailing address:
  • Phone: 415-363-0466
  • Fax: 415-859-9265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA85402
License Number StateCA

VIII. Authorized Official

Name: DR. SONIA D BELL
Title or Position: PRESIDENT
Credential: MD
Phone: 415-363-0466