Provider Demographics
NPI:1790265114
Name:AVERY, DAVID TIMOTHY
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:TIMOTHY
Last Name:AVERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 SICARD ST APT 22
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-4649
Mailing Address - Country:US
Mailing Address - Phone:530-822-6547
Mailing Address - Fax:
Practice Address - Street 1:1229 SICARD ST APT 22
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-4649
Practice Address - Country:US
Practice Address - Phone:530-822-6547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)