=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902580095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVALON HEALTHCARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2023
-----------------------------------------------------
Last Update Date | 06/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10915 DOWNS RD
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28134-8367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-756-7294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10915 DOWNS RD
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28134-8367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANTHONY MCNEILL
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 704-756-7294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------