Healthcare Provider Details

I. General information

NPI: 1083581649
Provider Name (Legal Business Name): MANUEL AVILA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6551 NORTH AVE
OAK PARK IL
60302-1020
US

IV. Provider business mailing address

3243 S 54TH AVE
CICERO IL
60804-3928
US

V. Phone/Fax

Practice location:
  • Phone: 708-790-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.036085
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: