Provider Demographics
NPI:1740458298
Name:AVALON DIAGNOSTICS LLC
Entity type:Organization
Organization Name:AVALON DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-892-6496
Mailing Address - Street 1:2009 INDEPENDENCE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-0215
Mailing Address - Country:US
Mailing Address - Phone:903-892-6496
Mailing Address - Fax:903-892-6368
Practice Address - Street 1:2009 INDEPENDENCE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-0215
Practice Address - Country:US
Practice Address - Phone:903-892-6496
Practice Address - Fax:903-892-6368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTS188OtherMEDICARE PTAN