Provider Demographics
NPI:1497349815
Name:AVALA PHYSICIAN NETWORK, LLC
Entity Type:Organization
Organization Name:AVALA PHYSICIAN NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-809-9888
Mailing Address - Street 1:19065 DR JOHN LAMBERT DR STE 2000
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1027
Mailing Address - Country:US
Mailing Address - Phone:225-610-7054
Mailing Address - Fax:985-801-3099
Practice Address - Street 1:19065 DR JOHN LAMBERT DR STE 2000A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-0997
Practice Address - Country:US
Practice Address - Phone:985-892-8934
Practice Address - Fax:985-801-3099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRWAY MEDICAL CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty