Healthcare Provider Details

I. General information

NPI: 1205519675
Provider Name (Legal Business Name): AVA CICIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3848 W CARSON ST STE 110
TORRANCE CA
90503-6704
US

IV. Provider business mailing address

3848 W CARSON ST STE 110
TORRANCE CA
90503-6704
US

V. Phone/Fax

Practice location:
  • Phone: 424-488-3191
  • Fax: 310-933-4803
Mailing address:
  • Phone: 424-488-3191
  • Fax: 310-933-4803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number304430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: