Healthcare Provider Details

I. General information

NPI: 1538306378
Provider Name (Legal Business Name): AVOLEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S. SILVER LAKE ST.
OCONOMOWOC WI
53066
US

IV. Provider business mailing address

206 S. SILVER LAKE ST.
OCONOMOWOC WI
53066
US

V. Phone/Fax

Practice location:
  • Phone: 262-567-3000
  • Fax: 262-567-5082
Mailing address:
  • Phone: 262-567-3000
  • Fax: 262-567-5082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4330-046
License Number StateWI

VIII. Authorized Official

Name: MRS. DEBRA MARY DANIELS
Title or Position: OWNER
Credential: CMT
Phone: 262-567-3000