Provider Demographics
NPI:1588016208
Name:COLEMAN, AVERY
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 S E ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2773
Mailing Address - Country:US
Mailing Address - Phone:909-388-9191
Mailing Address - Fax:
Practice Address - Street 1:2080 S E ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2773
Practice Address - Country:US
Practice Address - Phone:909-388-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22523167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760651178Medicaid