Healthcare Provider Details

I. General information

NPI: 1821363557
Provider Name (Legal Business Name): AVILA INTEGRATIVE MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 02/05/2016
Certification Date:
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 TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7987
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4867
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number31499
License Number StateCO

VIII. Authorized Official

Name: DR. ROBERT J AVILA
Title or Position: PRESIDENT
Credential: D.C., CCST, CCCN
Phone: 719-565-1276