=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053482521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERESA P. AVANTS, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25455 BARTON RD SUITE A204
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-799-8620
-----------------------------------------------------
Fax | 909-799-1708
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25455 BARTON RD SUITE A204
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-799-8620
-----------------------------------------------------
Fax | 909-799-1708
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TERESA PFIEFLE AVANTS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 909-799-8620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | G56066
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------