Provider Demographics
NPI:1003039132
Name:AVALON MEDICAL GROUP OF WHITTIER INC.
Entity Type:Organization
Organization Name:AVALON MEDICAL GROUP OF WHITTIER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-461-5030
Mailing Address - Street 1:16030 VENTURA BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2754
Mailing Address - Country:US
Mailing Address - Phone:818-461-5030
Mailing Address - Fax:818-461-5095
Practice Address - Street 1:16030 VENTURA BLVD
Practice Address - Street 2:STE 200
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2754
Practice Address - Country:US
Practice Address - Phone:818-461-5030
Practice Address - Fax:818-461-5095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33793302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization