Healthcare Provider Details

I. General information

NPI: 1245248400
Provider Name (Legal Business Name): ROBERT JOSEPH AVILA D.C., CCST, CCCN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3960 IVYWOOD LN
PUEBLO CO
81005-2567
US

IV. Provider business mailing address

3960 IVYWOOD LN
PUEBLO CO
81005-2567
US

V. Phone/Fax

Practice location:
  • Phone: 719-565-1276
  • Fax: 719-565-2313
Mailing address:
  • Phone: 719-565-1276
  • Fax: 719-565-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4867
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number4867
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number4867
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number4867
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4867
License Number StateCO
# 6
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number4867
License Number StateCO
# 7
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number4867
License Number StateCO
# 8
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number4867
License Number StateCO
# 9
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4867
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: