Basic Information
| Provider Information | |||||||||
| NPI: | 1750821633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVILA | ||||||||
| FirstName: | JEANINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VILLANUEVA | ||||||||
| OtherFirstName: | JEANINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 117 LONE SHADOW DR | ||||||||
| Address2: | |||||||||
| City: | HARKER HEIGHTS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765482523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085851560 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2511 TRIMMIER RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765421908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662732451 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2017 | ||||||||
| LastUpdateDate: | 02/27/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | H01330250 | HI | Y |
ID Information
| ID | Type | State | Issuer | Description | 1396198459 | 01 | TX | TRICARE PRIME | OTHER |