MEDICARE: AVON BEHAVIORAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1083432512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVON BEHAVIORAL SERVICES LLC

Provider Business Mailing Address
First Line	:	629 LOFTY LN SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8638
Country	:	US
Telephone Number	:	510-825-6012
Fax Number	:

Provider Business Practice Location Address
First Line	:	4485 VERDON ST UNIT 1161
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-4431
Country	:	US
Telephone Number	:	510-825-6012
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHAQUAIL M MONTGOMERY
Credential	:
Telephone Number	:	510-825-6012

Provider Enumeration Date	:	10/02/2024
Last Update Date	:	10/02/2024

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