Provider Demographics
NPI:1003696063
Name:AVERY, MARIO WILLIAM SR
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:WILLIAM
Last Name:AVERY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-3806
Mailing Address - Country:US
Mailing Address - Phone:937-591-8420
Mailing Address - Fax:
Practice Address - Street 1:908 CATHERINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-3806
Practice Address - Country:US
Practice Address - Phone:937-591-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide