Provider Demographics
NPI:1710916226
Name:AVILES, JOHNNY (DC)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:AVILES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:JOHNNY
Other - Middle Name:
Other - Last Name:AVILES-PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6333 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5702
Mailing Address - Country:US
Mailing Address - Phone:323-382-2046
Mailing Address - Fax:
Practice Address - Street 1:6333 WILSHIRE BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5702
Practice Address - Country:US
Practice Address - Phone:323-382-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29323111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC29323Medicare ID - Type Unspecified