MEDICARE: MARIELA AVILA RBT

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	247200000X	Other Technician	RBT-18-68729

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RBT-18-68729	OTHER		BACB

General Provider Information

NPI Number	:	1275099327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIELA AVILA RBT

Provider Business Mailing Address
First Line	:	16800 DALLAS PKWY STE 200
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-1961
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12650 N BEACH ST STE 145
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4243
Country	:	US
Telephone Number	:	682-238-1872
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2019
Last Update Date	:	02/13/2019

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