Provider Demographics
NPI:1477915361
Name:AVALON BODYWORKS
Entity Type:Organization
Organization Name:AVALON BODYWORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMP
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-510-6663
Mailing Address - Street 1:115 W MAGNOLIA ST
Mailing Address - Street 2:202
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 W MAGNOLIA ST
Practice Address - Street 2:202
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4300
Practice Address - Country:US
Practice Address - Phone:360-510-6663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60059184174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty