Provider Demographics
NPI:1689155657
Name:AVILA GUEVARA, RICARDO (SA-C)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:AVILA GUEVARA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3657 NW 35TH ST
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33066-2434
Mailing Address - Country:US
Mailing Address - Phone:754-368-5715
Mailing Address - Fax:
Practice Address - Street 1:3657 NW 35TH ST
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33066-2434
Practice Address - Country:US
Practice Address - Phone:754-368-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18369246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant