Basic Information
| Provider Information | |||||||||
| NPI: | 1275021792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVILA | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | N | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4575 SE DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349976826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5017 OAK AVE | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324662024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2018 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.