Provider Demographics
NPI:1417354481
Name:AVANAVA PC
Entity Type:Organization
Organization Name:AVANAVA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:THERATTIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-216-9422
Mailing Address - Street 1:71 WESTBURY CT
Mailing Address - Street 2:
Mailing Address - City:SKILLMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08558-1726
Mailing Address - Country:US
Mailing Address - Phone:609-216-9422
Mailing Address - Fax:609-896-4107
Practice Address - Street 1:2381 LAWRENCEVILLE RD
Practice Address - Street 2:ST.LAWRENCE REHABILITATION CENTER, DOCTORS OFFICES
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2025
Practice Address - Country:US
Practice Address - Phone:609-896-8152
Practice Address - Fax:609-896-4107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07576900208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty