MEDICARE: CHRISTAL 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	390200000X	Student in an Organized Health Care Education/Training Program
2	1041C0700X	Clinical Social Worker	88330	CA

General Provider Information

NPI Number	:	1912308149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTAL AVILA

Provider Business Mailing Address
First Line	:	11996 SPARTAN LN
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92337-9070
Country	:	US
Telephone Number	:	562-536-7584
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 E AIRPORT DR STE 138
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3428
Country	:	US
Telephone Number	:	562-536-7584
Fax Number	:	562-216-2337

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

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	09/26/2023

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Directions to “ CHRISTAL AVILA ” Practice Location

Language	Start Address	Practice Location

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