Provider Demographics
NPI:1154661841
Name:AVALON DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:AVALON DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-924-3903
Mailing Address - Street 1:208 W EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4710
Mailing Address - Country:US
Mailing Address - Phone:580-924-3903
Mailing Address - Fax:580-924-3904
Practice Address - Street 1:208 W EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4710
Practice Address - Country:US
Practice Address - Phone:580-924-3903
Practice Address - Fax:580-924-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic