Healthcare Provider Details

I. General information

NPI: 1538280698
Provider Name (Legal Business Name): KEVIN M AVILLA PT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 SATELLITE BLVD NW SUITE 100
SUWANEE GA
30024-4636
US

IV. Provider business mailing address

1180 SATELLITE BLVD NW SUITE 100
SUWANEE GA
30024-4636
US

V. Phone/Fax

Practice location:
  • Phone: 404-367-2080
  • Fax: 770-495-3493
Mailing address:
  • Phone: 404-367-2080
  • Fax: 770-495-3493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1356
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number20091
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT010906
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: