Provider Demographics
NPI:1700191525
Name:AVA SELF MANAGEMENT
Entity Type:Organization
Organization Name:AVA SELF MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:RIDDLING
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-756-4040
Mailing Address - Street 1:3001 W WACO DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-3272
Mailing Address - Country:US
Mailing Address - Phone:254-756-4040
Mailing Address - Fax:254-756-4042
Practice Address - Street 1:3001 W WACO DR
Practice Address - Street 2:SUITE B
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76707-3272
Practice Address - Country:US
Practice Address - Phone:254-756-4040
Practice Address - Fax:254-756-4042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5015111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty