Provider Demographics
NPI:1427568724
Name:AVICA, LLC
Entity Type:Organization
Organization Name:AVICA, LLC
Other - Org Name:TWO RAVENS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:DEWATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-804-1442
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33780-0101
Mailing Address - Country:US
Mailing Address - Phone:727-214-0427
Mailing Address - Fax:
Practice Address - Street 1:8790 53RD WAY N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-5180
Practice Address - Country:US
Practice Address - Phone:727-804-1442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities