Basic Information
| Provider Information | |||||||||
| NPI: | 1487937330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVILA | ||||||||
| FirstName: | RADOMIR | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | 6199064564 | ||||||||
| Practice Location | |||||||||
| Address1: | 248 LANDIS AVE | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919102609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW 37133 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 75520 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.