Provider Demographics
NPI:1205205770
Name:AVENTUS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:AVENTUS MEDICAL GROUP, LLC
Other - Org Name:AVENTUS MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:RETODO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:669-342-7711
Mailing Address - Street 1:12 S 1ST ST STE 811
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95113-2405
Mailing Address - Country:US
Mailing Address - Phone:669-342-7711
Mailing Address - Fax:669-342-7717
Practice Address - Street 1:12 S 1ST ST STE 811
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95113-2405
Practice Address - Country:US
Practice Address - Phone:669-342-7711
Practice Address - Fax:669-342-7717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty