Provider Demographics
NPI:1447618491
Name:AVADA
Entity Type:Organization
Organization Name:AVADA
Other - Org Name:OTICON
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-639-1557
Mailing Address - Street 1:160 PINEHURST AVE STE G
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7078
Mailing Address - Country:US
Mailing Address - Phone:910-692-4454
Mailing Address - Fax:910-246-0583
Practice Address - Street 1:160 PINEHURST AVE STE G
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-7078
Practice Address - Country:US
Practice Address - Phone:910-692-4454
Practice Address - Fax:910-246-0583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONE RETAIL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization