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General NPI Number Information
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NPI Number | 1700191525
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Entity Type | Organization
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Legal Business Name | AVA SELF MANAGEMENT
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Dates
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Enumeration Date | 08/17/2010
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Last Update Date | 08/17/2010
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Provider Practice Location Address
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Address Line | 3001 W WACO DR SUITE B
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City | WACO
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State | TX
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Zip | 76707-3272
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Country | US
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Telephone | 254-756-4040
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Fax | 254-756-4042
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Provider Business Mailing Address
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Address Line | 3001 W WACO DR SUITE B
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City | WACO
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State | TX
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Zip | 76707-3272
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Country | US
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Telephone | 254-756-4040
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Fax | 254-756-4042
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Authorized Official
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Title or Position | CEO
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Name | MRS. VICKI RIDDLING ELLISON
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Credential |
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Telephone | 254-756-4040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5015
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License Number State | TX
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