MEDICARE: MR. JUAN AVALOS

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	101Y00000X	Counselor
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1811043748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN AVALOS

Provider Business Mailing Address
First Line	:	1007 1/2 W 21ST ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90007-3092
Country	:	US
Telephone Number	:	213-749-0292
Fax Number	:

Provider Business Practice Location Address
First Line	:	631 MAPLE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90014-2211
Country	:	US
Telephone Number	:	213-305-3671
Fax Number	:	213-626-2458

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	03/19/2021

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