MEDICARE: MS. SHIRLEY AVILA

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1346452802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHIRLEY AVILA

Provider Business Mailing Address
First Line	:	295 W JACKSON ST
Second Line	:
City	:	RIALTO
State	:	CA
Zip	:	92376-4269
Country	:	US
Telephone Number	:	909-875-8369
Fax Number	:

Provider Business Practice Location Address
First Line	:	802 W COLTON AVE
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92374-2905
Country	:	US
Telephone Number	:	909-335-2989
Fax Number	:	909-335-1701

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/08/2007

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