Provider Demographics
NPI:1538280698
Name:AVILLA, KEVIN M (PT, ATC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:AVILLA
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Gender:M
Credentials:PT, ATC
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Mailing Address - Street 1:1180 SATELLITE BLVD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4636
Mailing Address - Country:US
Mailing Address - Phone:404-367-2080
Mailing Address - Fax:770-495-3493
Practice Address - Street 1:1180 SATELLITE BLVD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4636
Practice Address - Country:US
Practice Address - Phone:404-367-2080
Practice Address - Fax:770-495-3493
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2013-11-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA13562255A2300X
MA20091225100000X
GAPT010906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer