Provider Demographics
NPI:1750631925
Name:AVLC ALTOONA, LLC
Entity Type:Organization
Organization Name:AVLC ALTOONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:FABER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-515-9919
Mailing Address - Street 1:723 BROAD STREET
Mailing Address - Street 2:ROUTE 22
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635
Mailing Address - Country:US
Mailing Address - Phone:814-515-9919
Mailing Address - Fax:717-741-2204
Practice Address - Street 1:723 BROAD ST
Practice Address - Street 2:ROUTE 22
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635-9450
Practice Address - Country:US
Practice Address - Phone:814-515-9919
Practice Address - Fax:717-741-2204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065086L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA060266Medicare PIN