MEDICARE: MIKAYLA M AVILA LMT

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	225700000X	Massage Therapist	MT.0023246	CO

General Provider Information

NPI Number	:	1871258012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAYLA M AVILA LMT

Provider Business Mailing Address
First Line	:	2121 E SAINT VRAIN ST APT 6
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-4757
Country	:	US
Telephone Number	:	218-849-0100
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 E SAINT VRAIN ST APT 6
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-4757
Country	:	US
Telephone Number	:	218-849-0100
Fax Number	:

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

Provider Enumeration Date	:	11/02/2021
Last Update Date	:	11/02/2021

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